Provider Demographics
NPI:1790190155
Name:ALI, RUSTOM (PHD)
Entity Type:Individual
Prefix:DR
First Name:RUSTOM
Middle Name:
Last Name:ALI
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1968 MESQUITE AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-5729
Mailing Address - Country:US
Mailing Address - Phone:480-703-4227
Mailing Address - Fax:
Practice Address - Street 1:1968 MESQUITE AVE
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5729
Practice Address - Country:US
Practice Address - Phone:480-703-4227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-24
Last Update Date:2014-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ778154133NN1002X, 174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No174H00000XOther Service ProvidersHealth Educator