Provider Demographics
NPI:1568129286
Name:RUST, DIANNE (CMT)
Entity Type:Individual
Prefix:MISS
First Name:DIANNE
Middle Name:
Last Name:RUST
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:517 BLOSSOM HILL RD APT A14
Mailing Address - Street 2:
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95032-4537
Mailing Address - Country:US
Mailing Address - Phone:408-887-7107
Mailing Address - Fax:
Practice Address - Street 1:517 BLOSSOM HILL RD APT A14
Practice Address - Street 2:
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95032-4537
Practice Address - Country:US
Practice Address - Phone:408-887-7107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-17
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7990204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports MedicineGroup - Multi-Specialty