Provider Demographics
NPI:1972224673
Name:RUSTICH, DEREK SCOTT (DPT)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:SCOTT
Last Name:RUSTICH
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1412 PRIMROSE DR
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92020-5644
Mailing Address - Country:US
Mailing Address - Phone:619-510-5000
Mailing Address - Fax:619-303-4230
Practice Address - Street 1:13220 EVENING CREEK DR S STE 109
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-4103
Practice Address - Country:US
Practice Address - Phone:619-510-5000
Practice Address - Fax:619-303-4230
Is Sole Proprietor?:No
Enumeration Date:2022-09-09
Last Update Date:2025-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA302855225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist