Healthcare Provider Details

I. General information

NPI: 1891802005
Provider Name (Legal Business Name): ANDREW LEE RUST O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 CROSSROADS DR
PLOVER WI
54467-4124
US

IV. Provider business mailing address

1510 ASHWOOD DR
PLOVER WI
54467-2466
US

V. Phone/Fax

Practice location:
  • Phone: 715-345-9588
  • Fax:
Mailing address:
  • Phone: 715-341-6618
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2810
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: