Provider Demographics
NPI:1003922394
Name:OTRUSINIK, RUDOLF (MD)
Entity Type:Individual
Prefix:
First Name:RUDOLF
Middle Name:
Last Name:OTRUSINIK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SLC
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:435-755-8200
Mailing Address - Fax:435-752-6094
Practice Address - Street 1:1300 N 500 E
Practice Address - Street 2:SUITE 320
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2408
Practice Address - Country:US
Practice Address - Phone:435-755-8200
Practice Address - Fax:435-752-6094
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT95-292310-1205207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT581997OtherDMBA
UT87-0569381OtherTAX ID
UT107008634101OtherSELECTCARE
ID805433000Medicaid
UT060053972OtherRR MEDICARE
UT53687OtherPEHP
UT581997OtherDMBA
UT87-0569381OtherTAX ID