Provider Demographics
NPI:1306829973
Name:RUSTAD, TODD (MD)
Entity Type:Individual
Prefix:DR
First Name:TODD
Middle Name:
Last Name:RUSTAD
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 1:900 N LIBERTY ST
Mailing Address - Street 2:STE 400
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8704
Mailing Address - Country:US
Mailing Address - Phone:208-367-3320
Mailing Address - Fax:208-367-7474
Practice Address - Street 1:900 N LIBERTY ST
Practice Address - Street 2:STE 400
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8704
Practice Address - Country:US
Practice Address - Phone:208-367-3320
Practice Address - Fax:208-367-7474
Is Sole Proprietor?:No
Enumeration Date:2005-11-28
Last Update Date:2010-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7280207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID804236300Medicaid
ID804236300Medicaid
ID1137665Medicare PIN