Provider Demographics
NPI:1003089293
Name:RUSTICI, KATHLEEN MARIE (MD)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARIE
Last Name:RUSTICI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12631 E 17TH AVE
Mailing Address - Street 2:PO BOX 6511
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80045-2527
Mailing Address - Country:US
Mailing Address - Phone:303-724-2052
Mailing Address - Fax:
Practice Address - Street 1:2807 ROSLYN ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80238-2624
Practice Address - Country:US
Practice Address - Phone:303-403-6333
Practice Address - Fax:303-403-6325
Is Sole Proprietor?:No
Enumeration Date:2008-04-08
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO51637207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO86270745Medicaid
CO86270745Medicaid