Healthcare Provider Details

I. General information

NPI: 1679548614
Provider Name (Legal Business Name): RUDOLPH B. RUSTIN III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2006
Last Update Date: 09/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 JEFFERSON PARK AVE 4TH FLOOR
CHARLOTTESVILLE VA
22903-3363
US

IV. Provider business mailing address

PO BOX 9007
CHARLOTTESVILLE VA
22906-9007
US

V. Phone/Fax

Practice location:
  • Phone: 434-982-4411
  • Fax: 434-924-2260
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number14302
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number14302
License Number StateSC
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number0101258483
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: