Provider Demographics
NPI:1891802005
Name:RUST, ANDREW LEE (OD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:LEE
Last Name:RUST
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1510 ASHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:PLOVER
Mailing Address - State:WI
Mailing Address - Zip Code:54467-2466
Mailing Address - Country:US
Mailing Address - Phone:715-341-6618
Mailing Address - Fax:
Practice Address - Street 1:250 CROSSROADS DR
Practice Address - Street 2:
Practice Address - City:PLOVER
Practice Address - State:WI
Practice Address - Zip Code:54467-4124
Practice Address - Country:US
Practice Address - Phone:715-345-9588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2810152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38610300Medicaid
WIU82312Medicare UPIN
WI47246Medicare ID - Type Unspecified