Provider Demographics
NPI:1861474439
Name:VAN WYK, RUSTAN JOEL (DO)
Entity Type:Individual
Prefix:DR
First Name:RUSTAN
Middle Name:JOEL
Last Name:VAN WYK
Suffix:
Gender:M
Credentials:DO
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Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:128 DOCTOR HENRY NORRIS DR
Mailing Address - Street 2:
Mailing Address - City:RUTHERFORDTON
Mailing Address - State:NC
Mailing Address - Zip Code:28139-3165
Mailing Address - Country:US
Mailing Address - Phone:828-286-5576
Mailing Address - Fax:828-286-2278
Practice Address - Street 1:128 DOCTOR HENRY NORRIS DR
Practice Address - Street 2:
Practice Address - City:RUTHERFORDTON
Practice Address - State:NC
Practice Address - Zip Code:28139-3165
Practice Address - Country:US
Practice Address - Phone:828-286-5576
Practice Address - Fax:828-286-2278
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TNDO0000002787208800000X
NC200001545208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ013975Medicaid
NC1861474439Medicaid
NCH35752Medicare UPIN