Provider Demographics
NPI:1679548614
Name:RUSTIN, RUDOLPH B III (MD)
Entity Type:Individual
Prefix:
First Name:RUDOLPH
Middle Name:B
Last Name:RUSTIN
Suffix:III
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:PO BOX 9007
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22906-9007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1300 JEFFERSON PARK AVE
Practice Address - Street 2:4TH FLOOR
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22903-3363
Practice Address - Country:US
Practice Address - Phone:434-982-4411
Practice Address - Fax:434-924-2260
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC14302208600000X, 208C00000X
VA0101258483208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1679548614Medicaid
SC143026Medicaid
SCE124756711Medicare PIN
SCE12475Medicare UPIN
SC143026Medicaid