Provider Demographics
NPI:1346376308
Name:RUST, GEORGE STABEN (MD)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:STABEN
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 1:1115 W CALL ST
Mailing Address - Street 2:FSU-COM, DEPT OF BSSM
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32304-3556
Mailing Address - Country:US
Mailing Address - Phone:850-644-1543
Mailing Address - Fax:
Practice Address - Street 1:2911 ROBERTS AVE
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32310-5007
Practice Address - Country:US
Practice Address - Phone:850-644-1543
Practice Address - Fax:855-230-7421
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME462562083P0901X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA08BDCTNMedicare ID - Type Unspecified
GAD62573Medicare UPIN
GA000476847AMedicaid