Healthcare Provider Details

I. General information

NPI: 1477537801
Provider Name (Legal Business Name): RUSTICO V SIMPELO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 07/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 FRIZZELL ST
POTOSI MO
63664-1505
US

IV. Provider business mailing address

300 HEALTHWAY
POTOSI MO
63664-1420
US

V. Phone/Fax

Practice location:
  • Phone: 573-438-5408
  • Fax: 573-438-2419
Mailing address:
  • Phone: 573-438-5408
  • Fax: 573-438-2419

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number33913
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number33913
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: