Healthcare Provider Details

I. General information

NPI: 1154374171
Provider Name (Legal Business Name): NASER RUSTOM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

Provider Other Name: NASER RUSTOM MD

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4941 N KEDZIE AVE
CHICAGO IL
60625-5009
US

IV. Provider business mailing address

4941 N KEDZIE AVE
CHICAGO IL
60625-5009
US

V. Phone/Fax

Practice location:
  • Phone: 773-509-9099
  • Fax: 773-509-9006
Mailing address:
  • Phone: 773-509-9099
  • Fax: 773-509-9006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: