Provider Demographics
NPI:1457435752
Name:RUST, CHARLES A (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:A
Last Name:RUST
Suffix:
Gender:M
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:PO BOX 45443
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84145-0443
Mailing Address - Country:US
Mailing Address - Phone:904-202-1032
Mailing Address - Fax:904-376-4107
Practice Address - Street 1:3690 SAINT JOHNS BLUFF RD S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-2616
Practice Address - Country:US
Practice Address - Phone:904-564-4343
Practice Address - Fax:904-224-7051
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME60414207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD24383Medicare UPIN
FL32812XMedicare PIN
FLD24383Medicare UPIN
FL2517434-00Medicaid
FLD24383Medicare UPIN
FL2517434-00Medicaid
FL5478142OtherAETNA
FL213209OtherAVMED
FL32812YMedicare ID - Type Unspecified