Basic Information
| Provider Information | |||||||||
| NPI: | 1174586440 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUSTAD | ||||||||
| FirstName: | OLAF | ||||||||
| MiddleName: | JONATHAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RUSTAD | ||||||||
| OtherFirstName: | OLAF | ||||||||
| OtherMiddleName: | JONATHAN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4480 CENTERVILLE ROAD | ||||||||
| Address2: | |||||||||
| City: | WHITE BEAR LAKE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551273674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6514842724 | ||||||||
| FaxNumber: | 6514842723 | ||||||||
| Practice Location | |||||||||
| Address1: | 4480 CENTERVILLE ROAD | ||||||||
| Address2: | |||||||||
| City: | WHITE BEAR LAKE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551273674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6514842724 | ||||||||
| FaxNumber: | 6514842723 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2006 | ||||||||
| LastUpdateDate: | 09/29/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 1938363 | MN | Y | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 070003227 | 01 | RR MEDICARE PIN | OTHER |