Provider Demographics
NPI:1912930777
Name:RUSTEN, MARK C (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:C
Last Name:RUSTEN
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 1:1050 W 10TH ST
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-2905
Mailing Address - Country:US
Mailing Address - Phone:573-364-9000
Mailing Address - Fax:
Practice Address - Street 1:1050 W 10TH ST
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-2905
Practice Address - Country:US
Practice Address - Phone:573-364-9000
Practice Address - Fax:573-202-2484
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY39450207Y00000X
MO2013000673207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000727593OtherBLUE CROSS BLUE SHIELD
KY64105109Medicaid
KYK008580Medicare PIN
1284704Medicare ID - Type Unspecified
KY64105109Medicaid