Provider Demographics
NPI:1174644363
Name:GUSTAFSON, THOMAS W (DC)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:W
Last Name:GUSTAFSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 STATE ROUTE 34 S
Mailing Address - Street 2:SUITE C
Mailing Address - City:COLTS NECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07722-1783
Mailing Address - Country:US
Mailing Address - Phone:732-683-0200
Mailing Address - Fax:732-683-1004
Practice Address - Street 1:81 STATE ROUTE 34 S
Practice Address - Street 2:SUITE C
Practice Address - City:COLTS NECK
Practice Address - State:NJ
Practice Address - Zip Code:07722-1783
Practice Address - Country:US
Practice Address - Phone:732-683-0200
Practice Address - Fax:732-683-1004
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2010-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00554200111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ223746483OtherTAX IDENTIFICATON NUMBER