Provider Demographics
NPI:1114919420
Name:GUSTAFSON, GARARD MELVIN (OD)
Entity Type:Individual
Prefix:DR
First Name:GARARD
Middle Name:MELVIN
Last Name:GUSTAFSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 MILTON WAY
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:WA
Mailing Address - Zip Code:98354-8800
Mailing Address - Country:US
Mailing Address - Phone:253-922-0333
Mailing Address - Fax:253-922-7322
Practice Address - Street 1:101 MILTON WAY
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:WA
Practice Address - Zip Code:98354-8800
Practice Address - Country:US
Practice Address - Phone:253-922-0333
Practice Address - Fax:253-922-7322
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-22
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00000938152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2343002Medicaid
WAT02709Medicare UPIN
WA0495760001Medicare NSC
WAG001000439Medicare ID - Type UnspecifiedOPTOMETRIST