Basic Information
Provider Information | |||||||||
NPI: | 1265442115 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RUTSTEIN | ||||||||
FirstName: | ROBERT | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | O.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1716 UNIVERSITY BLVD | ||||||||
Address2: | HPB G080A | ||||||||
City: | BIRMINGHAM | ||||||||
State: | AL | ||||||||
PostalCode: | 352940010 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2059752020 | ||||||||
FaxNumber: | 2059346755 | ||||||||
Practice Location | |||||||||
Address1: | 1716 UNIVERSITY BLVD | ||||||||
Address2: | HPB G080A | ||||||||
City: | BIRMINGHAM | ||||||||
State: | AL | ||||||||
PostalCode: | 352940010 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2059752020 | ||||||||
FaxNumber: | 2059346755 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/09/2006 | ||||||||
LastUpdateDate: | 08/31/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | T046TA120 | AL | Y |   | Eye and Vision Services Providers | Optometrist |   |
ID Information
ID | Type | State | Issuer | Description | 000059817 | 05 | AL |   | MEDICAID | A1716 636005396 | 01 | AL | VISION SERVICE PLAN | OTHER | 000059878 | 05 | AL |   | MEDICAID | 07276757 | 05 | MS |   | MEDICAID | 1585955 | 05 | LA |   | MEDICAID | 51059817 | 01 | AL | BCBS OF ALABAMA | OTHER | 51059878 | 01 | AL | BCBS | OTHER | T69052 | 01 | AL | VIVA | OTHER |