Provider Demographics
NPI:1942461512
Name:RUSTICO, STACY (MD)
Entity Type:Individual
Prefix:DR
First Name:STACY
Middle Name:
Last Name:RUSTICO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:STACY
Other - Middle Name:
Other - Last Name:DODT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:34800 BOB WILSON DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92134-2098
Mailing Address - Country:US
Mailing Address - Phone:619-881-9165
Mailing Address - Fax:619-532-9184
Practice Address - Street 1:34520 BOB WILSON DRIVE NAVAL MEDICAL CENTER SAN DIEGO
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-0001
Practice Address - Country:US
Practice Address - Phone:619-881-9165
Practice Address - Fax:619-532-9184
Is Sole Proprietor?:No
Enumeration Date:2008-06-17
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA111715208000000X
PAMT201749390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics