Provider Demographics
NPI:1003836016
Name:GUSTAFSON, JOHN CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:CHARLES
Last Name:GUSTAFSON
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 1:2795 LOMA VISTA RD
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-1544
Mailing Address - Country:US
Mailing Address - Phone:805-643-8695
Mailing Address - Fax:805-643-2087
Practice Address - Street 1:2795 LOMA VISTA RD
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-1544
Practice Address - Country:US
Practice Address - Phone:805-643-8695
Practice Address - Fax:805-643-2087
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG36782207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARHM08608FMedicaid
CAZZZ82842ZMedicaid
CARHM08609FMedicaid
CA050394OtherBLUE CROSS
CARHM18553HMedicaid
CAZZT40394FMedicaid
CA951683892OtherOTHER INSURANCE
CA953152550OtherOTHER INSURANCE
CAZZT40394FMedicaid
CARHM08609FMedicaid
CA058553Medicare ID - Type UnspecifiedRH MEDICARE
CAZZZ82842ZMedicaid
A46801Medicare UPIN