Provider Demographics
NPI:1013978568
Name:RUSTAD, DAVID G (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:G
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 1:2530 CHICAGO AVE
Mailing Address - Street 2:#550
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-4289
Mailing Address - Country:US
Mailing Address - Phone:612-813-8000
Mailing Address - Fax:612-813-8005
Practice Address - Street 1:7710 COMPUTER AVE
Practice Address - Street 2:#110
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-5417
Practice Address - Country:US
Practice Address - Phone:952-835-9442
Practice Address - Fax:952-835-9443
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN302222086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN837782100Medicaid
MN837782100Medicaid
MNA96122Medicare UPIN