Provider Demographics
NPI:1801079934
Name:RUST, RANDALL THOMAS (MD)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:THOMAS
Last Name:RUST
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5151 WINTER GARDEN VINELAND RD STE 206
Mailing Address - Street 2:
Mailing Address - City:WINDERMERE
Mailing Address - State:FL
Mailing Address - Zip Code:34786-6098
Mailing Address - Country:US
Mailing Address - Phone:407-573-3360
Mailing Address - Fax:407-643-2811
Practice Address - Street 1:5151 WINTER GARDEN VINELAND RD STE 206
Practice Address - Street 2:
Practice Address - City:WINDERMERE
Practice Address - State:FL
Practice Address - Zip Code:34786-6098
Practice Address - Country:US
Practice Address - Phone:407-573-3360
Practice Address - Fax:407-643-2811
Is Sole Proprietor?:No
Enumeration Date:2007-12-12
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME100461207X00000X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
1497ROtherBCBS
FL003892600Medicaid
622976OtherWELLCARE
01440170OtherAMERIGROUP
3195285OtherUNITED HEALTHCARE
348451OtherAVMED
7534257OtherCIGNA
9605661OtherAETNA
P992885OtherFREEDOM
3195285OtherUNITED HEALTHCARE