Provider Demographics
NPI:1578533170
Name:DOBRUSIN, RICHARD S (DO)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:S
Last Name:DOBRUSIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25500 N NORTERRA DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-8200
Mailing Address - Country:US
Mailing Address - Phone:623-277-2370
Mailing Address - Fax:
Practice Address - Street 1:3805 E BELL RD FL 2
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-2105
Practice Address - Country:US
Practice Address - Phone:800-233-3264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2578204D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ2578OtherSTATE LICENSE
ZWMBQL01Medicare ID - Type Unspecified
E25176Medicare UPIN