Provider Demographics
NPI:1679683742
Name:RUSHANAEDY, AGUSTINUS (MD)
Entity Type:Individual
Prefix:
First Name:AGUSTINUS
Middle Name:
Last Name:RUSHANAEDY
Suffix:
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 31309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0309
Mailing Address - Country:US
Mailing Address - Phone:323-865-3700
Mailing Address - Fax:
Practice Address - Street 1:6001 TRUXTUN AVE
Practice Address - Street 2:SUITE 220
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93309-0679
Practice Address - Country:US
Practice Address - Phone:661-323-6660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2016-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OROR MD 14298208800000X
WAMD 00033485208800000X
CAA41710208800000X
HIMD 10824208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology