Healthcare Provider Details

I. General information

NPI: 1437214202
Provider Name (Legal Business Name): ROBERT EDWARD RUST JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2006
Last Update Date: 10/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 N DIVISION AVE
SANDPOINT ID
83864-8268
US

IV. Provider business mailing address

1301 N DIVISION AVE
SANDPOINT ID
83864-8268
US

V. Phone/Fax

Practice location:
  • Phone: 208-263-1345
  • Fax: 208-255-5531
Mailing address:
  • Phone: 208-290-3567
  • Fax: 208-255-5531

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM3004
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberM-3004
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: