Provider Demographics
NPI:1154371292
Name:RUSCH, MARIA THERESA (MD)
Entity type:Individual
Prefix:DR
First Name:MARIA
Middle Name:THERESA
Last Name:RUSCH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MARIA
Other - Middle Name:THERESA
Other - Last Name:SAN AGUSTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:396 W PUTNAM AVE
Mailing Address - Street 2:
Mailing Address - City:PORTERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:93257-3323
Mailing Address - Country:US
Mailing Address - Phone:559-781-5022
Mailing Address - Fax:559-781-6990
Practice Address - Street 1:396 W PUTNAM AVE
Practice Address - Street 2:
Practice Address - City:PORTERVILLE
Practice Address - State:CA
Practice Address - Zip Code:93257-3323
Practice Address - Country:US
Practice Address - Phone:559-781-5022
Practice Address - Fax:559-781-6990
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY205725-1208000000X
CAC51083208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG10017Medicare UPIN