Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 204D00000X | Neuromusculoskeletal Medicine (NMM) | 2578 | AZ |
Y | 207Q00000X | Family Doctor | 2578 | AZ |
NPI | 1578533170 |
---|---|
Provider Name | Richard S Dobrusin |
First Address | Phoenix, AZ 85085-8200 |
Second Address | Phoenix, AZ 85032-2105 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/01/2006 |
Last Update Date | 06/12/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
2578 | STATE LICENSE (01) | AZ |
E25176 | (02) |