Provider Demographics
NPI:1003980178
Name:GUSTAFSON, GAY L (DPM)
Entity Type:Individual
Prefix:
First Name:GAY
Middle Name:L
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7700 MENAUL BLVD NE
Mailing Address - Street 2:STE D
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-4616
Mailing Address - Country:US
Mailing Address - Phone:505-299-4487
Mailing Address - Fax:505-299-4498
Practice Address - Street 1:7700 MENAUL BLVD NE
Practice Address - Street 2:STE D
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-4616
Practice Address - Country:US
Practice Address - Phone:505-299-4487
Practice Address - Fax:505-299-4498
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM252213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMQ4698Medicaid
U66743Medicare UPIN
NM$$$$$$$$$PMedicare PIN