Provider Demographics
NPI:1831190834
Name:RUSTOM, AMAL (MD)
Entity type:Individual
Prefix:DR
First Name:AMAL
Middle Name:
Last Name:RUSTOM
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 1:8010 STAGE HILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:TN
Mailing Address - Zip Code:38133-4032
Mailing Address - Country:US
Mailing Address - Phone:901-291-2400
Mailing Address - Fax:901-379-0771
Practice Address - Street 1:7691 POPLAR AVE
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-3904
Practice Address - Country:US
Practice Address - Phone:901-516-6970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN27218207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3836613Medicaid
TNP00178629Medicare PIN
TNG86992Medicare UPIN
TN3836613Medicare ID - Type Unspecified