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NPI Code Detail

MEDICARE: OLAF JONATHAN RUSTAD MD

MEDICARE: OLAF JONATHAN RUSTAD MD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207N00000XDermatology Physician1938363MN

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1070003227OTHERRR MEDICARE PIN

General Provider Information

NPI Number : 1174586440
Entity Type Code : Individual
Provider Name (Legal Business Name) : OLAF JONATHAN RUSTAD MD
Provider Business Mailing Address
First Line : 4480 CENTERVILLE ROAD
Second Line :
City : WHITE BEAR LAKE
State : MN
Zip : 55127-3674
Country : US
Telephone Number : 651-484-2724
Fax Number : 651-484-2723
Provider Business Practice Location Address
First Line : 4480 CENTERVILLE ROAD
Second Line :
City : WHITE BEAR LAKE
State : MN
Zip : 55127-3674
Country : US
Telephone Number : 651-484-2724
Fax Number : 651-484-2723
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/08/2006
Last Update Date : 09/29/2010

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