Provider Demographics
NPI:1689961344
Name:RUST, BLAKE S (O D)
Entity Type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:S
Last Name:RUST
Suffix:
Gender:M
Credentials:O D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11124 KINGSTON PIKE
Mailing Address - Street 2:SUITE 127
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37934-2863
Mailing Address - Country:US
Mailing Address - Phone:865-966-2020
Mailing Address - Fax:865-966-7332
Practice Address - Street 1:11124 KINGSTON PIKE
Practice Address - Street 2:SUITE 127
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37934-2863
Practice Address - Country:US
Practice Address - Phone:865-966-2020
Practice Address - Fax:865-966-7332
Is Sole Proprietor?:No
Enumeration Date:2011-07-01
Last Update Date:2011-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2981152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist