Provider Demographics
NPI:1144208273
Name:LEFSRUD, ROBERT D (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:D
Last Name:LEFSRUD
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 1:1024 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RICE LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54868-1236
Mailing Address - Country:US
Mailing Address - Phone:715-234-8151
Mailing Address - Fax:715-234-9750
Practice Address - Street 1:1024 N MAIN ST
Practice Address - Street 2:
Practice Address - City:RICE LAKE
Practice Address - State:WI
Practice Address - Zip Code:54868-1236
Practice Address - Country:US
Practice Address - Phone:715-234-8151
Practice Address - Fax:715-234-9750
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI439582085R0202X
MN385402085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN131314200Medicaid
WI32370800Medicaid
MNG20294Medicare UPIN
MN300001697Medicare ID - Type Unspecified