=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972224673
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEREK SCOTT RUSTICH DPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/09/2022
-----------------------------------------------------
Last Update Date | 09/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13220 EVENING CREEK DR S STE 109
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92128-4103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-510-5000
-----------------------------------------------------
Fax | 619-303-4230
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1412 PRIMROSE DR
-----------------------------------------------------
City | EL CAJON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92020-5644
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-510-5000
-----------------------------------------------------
Fax | 619-303-4230
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 302855
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------