Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | M3004 | ID |
Y | 207QA0401X | Family Doctor - Addiction Medicine | M-3004 | ID |
NPI | 1437214202 |
---|---|
Provider Name | Dr. Robert Edward Rust JR. |
First Address | Sandpoint, ID 83864-8268 |
Second Address | Sandpoint, ID 83864-8268 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 22/12/2006 |
Last Update Date | 17/10/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
112500019 | (05) | ID |
E75470 | (02) | ID |