Provider Demographics
NPI:1356407613
Name:TROY E RUSTAD, MD, PA
Entity type:Organization
Organization Name:TROY E RUSTAD, MD, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TROY
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSTAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:612-227-8769
Mailing Address - Street 1:3334 WOODSSHIRE PARKWAY
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68502
Mailing Address - Country:US
Mailing Address - Phone:612-227-8769
Mailing Address - Fax:
Practice Address - Street 1:3334 WOODSSHIRE PARKWAY
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68502
Practice Address - Country:US
Practice Address - Phone:612-227-8769
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-29
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN070000554Medicare ID - Type Unspecified