Provider Demographics
NPI:1821652686
Name:RANDALL S. PRUST MD PC
Entity Type:Organization
Organization Name:RANDALL S. PRUST MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:S
Authorized Official - Last Name:PRUST
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:520-731-5540
Mailing Address - Street 1:4747 E CAMP LOWELL DR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-1256
Mailing Address - Country:US
Mailing Address - Phone:520-731-5540
Mailing Address - Fax:520-731-5541
Practice Address - Street 1:6060 N FOUNTAIN PLAZA DR STE 170
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-7875
Practice Address - Country:US
Practice Address - Phone:520-731-5540
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-26
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty