Provider Demographics
NPI:1568711406
Name:RUSIN, JOHN STATE (PT, DPT, CSCS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:STATE
Last Name:RUSIN
Suffix:
Gender:M
Credentials:PT, DPT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1241 PROSPECT ST
Mailing Address - Street 2:APARTMENT 5
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037
Mailing Address - Country:US
Mailing Address - Phone:716-481-0675
Mailing Address - Fax:
Practice Address - Street 1:1241 PROSPECT ST
Practice Address - Street 2:APARTMENT 5
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-0000
Practice Address - Country:US
Practice Address - Phone:716-481-0675
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-06
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39331174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist