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General NPI Number Information
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NPI Number | 1861474439
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Entity Type | Individual
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Provider Name | RUSTAN JOEL VAN WYK D.O.
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Gender | Male
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Dates
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Enumeration Date | 11/18/2005
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Last Update Date | 11/18/2025
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Provider Practice Location Address
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Address Line | 275 BETHESDA DR
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City | GREENVILLE
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State | NC
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Zip | 27834-7217
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Country | US
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Telephone | 252-752-5077
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Fax |
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Provider Business Mailing Address
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Address Line | 275 BETHESDA DR
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City | GREENVILLE
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State | NC
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Zip | 27834-7217
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Country | US
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Telephone | 252-752-5077
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208800000X
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Taxonomy Name | Urology Physician
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License Number | DO0000002787
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License Number State | TN
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Taxonomy #2
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Taxonomy Code | 208800000X
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Taxonomy Name | Urology Physician
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License Number | 200001545
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License Number State | NC
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