Healthcare Provider Details

I. General information

NPI: 1801079934
Provider Name (Legal Business Name): RANDALL THOMAS RUST MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2007
Last Update Date: 11/24/2020
Certification Date: 11/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5151 WINTER GARDEN VINELAND RD STE 206
WINDERMERE FL
34786-6098
US

IV. Provider business mailing address

5151 WINTER GARDEN VINELAND RD STE 206
WINDERMERE FL
34786-6098
US

V. Phone/Fax

Practice location:
  • Phone: 407-573-3360
  • Fax: 407-643-2811
Mailing address:
  • Phone: 407-573-3360
  • Fax: 407-643-2811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberME100461
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: