Provider Demographics
NPI:1073555629
Name:GUSTAFSON, L MARK (MD)
Entity Type:Individual
Prefix:
First Name:L
Middle Name:MARK
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 1:150 CLINIC AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-4401
Mailing Address - Country:US
Mailing Address - Phone:770-832-1488
Mailing Address - Fax:
Practice Address - Street 1:150 CLINIC AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-4401
Practice Address - Country:US
Practice Address - Phone:770-832-1488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA049795207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA841043OtherBLUE CROSS CLUE SHIELD
GA00906463CMedicaid
GA00906463BMedicaid
GA00906463BMedicaid
GA04BDCFSMedicare PIN
GA040016046Medicare PIN