Provider Demographics
NPI:1003981044
Name:GUSTOVICH, CARLA (MD)
Entity Type:Individual
Prefix:DR
First Name:CARLA
Middle Name:
Last Name:GUSTOVICH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13192 DALLAS PKWY STE 620
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75033-4248
Mailing Address - Country:US
Mailing Address - Phone:972-668-3376
Mailing Address - Fax:972-668-7546
Practice Address - Street 1:13192 DALLAS PKWY STE 620
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75033-4248
Practice Address - Country:US
Practice Address - Phone:972-668-3376
Practice Address - Fax:972-668-7546
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL6625207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
I21640Medicare UPIN
TX8C8283Medicare ID - Type Unspecified