Provider Demographics
NPI:1174586440
Name:RUSTAD, OLAF JONATHAN (MD)
Entity type:Individual
Prefix:
First Name:OLAF
Middle Name:JONATHAN
Last Name:RUSTAD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:OLAF
Other - Middle Name:JONATHAN
Other - Last Name:RUSTAD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:4480 CENTERVILLE ROAD
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55127-3674
Mailing Address - Country:US
Mailing Address - Phone:651-484-2724
Mailing Address - Fax:651-484-2723
Practice Address - Street 1:4480 CENTERVILLE ROAD
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55127-3674
Practice Address - Country:US
Practice Address - Phone:651-484-2724
Practice Address - Fax:651-484-2723
Is Sole Proprietor?:No
Enumeration Date:2006-04-08
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1938363207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
070003227OtherRR MEDICARE PIN
MND98155Medicare UPIN
070003227OtherRR MEDICARE PIN