Provider Demographics
NPI:1255330809
Name:DAMANIA, RUSTOM F
Entity Type:Individual
Prefix:DR
First Name:RUSTOM
Middle Name:F
Last Name:DAMANIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 W BULLARD AVE
Mailing Address - Street 2:113
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93612-0861
Mailing Address - Country:US
Mailing Address - Phone:559-298-7819
Mailing Address - Fax:
Practice Address - Street 1:255 W BULLARD AVE
Practice Address - Street 2:113
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93612-0861
Practice Address - Country:US
Practice Address - Phone:559-298-7819
Practice Address - Fax:559-298-5834
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-17
Last Update Date:2024-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA322130207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A322130Medicaid
CA00A322130Medicare ID - Type UnspecifiedMEDICARE
CA00A322130Medicaid