Provider Demographics
NPI:1437214202
Name:RUST, ROBERT EDWARD JR (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:EDWARD
Last Name:RUST
Suffix:JR
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 1:1301 N DIVISION AVE
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-8268
Mailing Address - Country:US
Mailing Address - Phone:208-290-3567
Mailing Address - Fax:208-255-5531
Practice Address - Street 1:1301 N DIVISION AVE
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-8268
Practice Address - Country:US
Practice Address - Phone:208-263-1345
Practice Address - Fax:208-255-5531
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2013-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM3004207Q00000X
IDM-3004207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID112500019Medicaid
ID112500019Medicaid