Provider Demographics
NPI:1497193569
Name:RUST, LAUREN (MD)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:RUST
Suffix:
Gender:F
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 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:36 MCNEILL PLZ
Practice Address - Street 2:
Practice Address - City:WHITEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28472-8602
Practice Address - Country:US
Practice Address - Phone:910-640-4064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-11
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2016-00923208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNC2794Medicaid
NC1497193569Medicaid
SCNC2794Medicaid