Provider Demographics
NPI:1689631038
Name:RUSTAD, RUTH A (MD)
Entity Type:Individual
Prefix:
First Name:RUTH
Middle Name:A
Last Name:RUSTAD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:RUTH
Other - Middle Name:A
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4480 CENTERVILLE RD
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 RD
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:2006-04-28
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN38316207R00000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN110202652OtherRR MEDICARE
MN110202652OtherRR MEDICARE
G60659Medicare UPIN