Provider Demographics
NPI:1154684355
Name:RUST, STEFANIE NICOLE (DO)
Entity Type:Individual
Prefix:DR
First Name:STEFANIE
Middle Name:NICOLE
Last Name:RUST
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2201 WEST LAMPASAS STREET
Mailing Address - Street 2:
Mailing Address - City:ENNIS
Mailing Address - State:TX
Mailing Address - Zip Code:75119
Mailing Address - Country:US
Mailing Address - Phone:972-875-0900
Mailing Address - Fax:
Practice Address - Street 1:2201 WEST LAMPASAS STREET
Practice Address - Street 2:
Practice Address - City:ENNIS
Practice Address - State:TX
Practice Address - Zip Code:75119
Practice Address - Country:US
Practice Address - Phone:972-875-0900
Practice Address - Fax:469-256-2154
Is Sole Proprietor?:No
Enumeration Date:2012-06-21
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ4269207Q00000X
ARE8294207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR201593001Medicaid
AR330926YH21Medicare PIN