Provider Demographics
NPI:1033116611
Name:PRUST, RANDALL S (MD)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:S
Last Name:PRUST
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 1:4747 E CAMP LOWELL DR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-1256
Mailing Address - Country:US
Mailing Address - Phone:520-731-5540
Mailing Address - Fax:520-731-5541
Practice Address - Street 1:4747 E CAMP LOWELL DR
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-1256
Practice Address - Country:US
Practice Address - Phone:520-731-5540
Practice Address - Fax:520-731-5541
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2017-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ15163207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZD37479Medicare UPIN
AZZWMBJZMedicare PIN