Provider Demographics
NPI:1134108756
Name:GUSTAFSON, MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
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 1:1802 BRAEBURN DR
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:VA
Mailing Address - Zip Code:24153-7357
Mailing Address - Country:US
Mailing Address - Phone:540-772-3520
Mailing Address - Fax:540-772-5975
Practice Address - Street 1:1802 BRAEBURN DR
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-7357
Practice Address - Country:US
Practice Address - Phone:540-772-3520
Practice Address - Fax:540-772-5975
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101038915207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAP00276916OtherMEDICARE RAILROAD
B06460Medicare UPIN
VA00W725L51Medicare ID - Type UnspecifiedRICHMOND MEDICARE