Provider Demographics
NPI:1679698336
Name:RUST, JACK R (PHYSICAL THERAPIST)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:R
Last Name:RUST
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1940 NE 45 ST
Mailing Address - Street 2:#3
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308
Mailing Address - Country:US
Mailing Address - Phone:954-938-0154
Mailing Address - Fax:954-492-1151
Practice Address - Street 1:1940 NE 45 ST
Practice Address - Street 2:#3
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308
Practice Address - Country:US
Practice Address - Phone:954-938-0154
Practice Address - Fax:954-492-1151
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT0000326225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLV0007Medicare ID - Type Unspecified