Provider Demographics
NPI:1942317888
Name:HOLLERUD, JOHN ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ROBERT
Last Name:HOLLERUD
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 1:11107 ULYSSES ST NE STE 100
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55434-4264
Mailing Address - Country:US
Mailing Address - Phone:763-333-7733
Mailing Address - Fax:763-333-7711
Practice Address - Street 1:11107 ULYSSES ST NE STE 100
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55434-4264
Practice Address - Country:US
Practice Address - Phone:763-333-7733
Practice Address - Fax:763-333-7711
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN36159208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN895363500Medicaid