Provider Demographics
NPI:1225255086
Name:GUSTAVSON, KURT (DPM)
Entity Type:Individual
Prefix:DR
First Name:KURT
Middle Name:
Last Name:GUSTAVSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6216 WHISPER LN SW
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-1139
Mailing Address - Country:US
Mailing Address - Phone:253-968-1613
Mailing Address - Fax:
Practice Address - Street 1:6216 WHISPER LN SW
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-1139
Practice Address - Country:US
Practice Address - Phone:253-968-1613
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT99213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT99OtherSTATE LICENSE
T91951Medicare UPIN