Basic Information
| Provider Information | |||||||||
| NPI: | 1821652686 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RANDALL S. PRUST MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4747 E CAMP LOWELL DR | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857121256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207315540 | ||||||||
| FaxNumber: | 5207315541 | ||||||||
| Practice Location | |||||||||
| Address1: | 6060 N FOUNTAIN PLAZA DR STE 170 | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857047875 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207315540 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2019 | ||||||||
| LastUpdateDate: | 04/26/2019 | ||||||||
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| AuthorizedOfficialLastName: | PRUST | ||||||||
| AuthorizedOfficialFirstName: | RANDALL | ||||||||
| AuthorizedOfficialMiddleName: | S. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5207315540 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0014X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
No ID Information.