Provider Demographics
NPI:1225253693
Name:GUSTAFSON, THOMAS PAUL (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:PAUL
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 1:490 OWASSO HILLS DR
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-2153
Mailing Address - Country:US
Mailing Address - Phone:612-759-3476
Mailing Address - Fax:
Practice Address - Street 1:11725 STINSON AVE
Practice Address - Street 2:
Practice Address - City:CHISAGO CITY
Practice Address - State:MN
Practice Address - Zip Code:55013-9542
Practice Address - Country:US
Practice Address - Phone:651-257-8499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2012-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN49732207QS1201X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS1201XAllopathic & Osteopathic PhysiciansFamily MedicineSleep Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine