Provider Demographics
NPI:1093775199
Name:GUSTAFSON, GARY S (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:S
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 1:44378 DEQUINDRE RD
Mailing Address - Street 2:STERLING HEIGHTS
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48314-1003
Mailing Address - Country:US
Mailing Address - Phone:248-964-3070
Mailing Address - Fax:248-964-0057
Practice Address - Street 1:44378 DEQUINDRE RD
Practice Address - Street 2:STERLING HEIGHTS
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48314-1003
Practice Address - Country:US
Practice Address - Phone:248-964-3070
Practice Address - Fax:248-964-0057
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010464242085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2588472Medicaid
MI320F362430OtherBCBSM
MIA94290Medicare UPIN
MI0F36076009Medicare ID - Type Unspecified