Provider Demographics
NPI:1275518946
Name:GUSTAFSON, RANDALL LEE (PT)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:LEE
Last Name:GUSTAFSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5962 LA PLACE CT
Mailing Address - Street 2:STE 170
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008
Mailing Address - Country:US
Mailing Address - Phone:800-929-4776
Mailing Address - Fax:760-931-8370
Practice Address - Street 1:7510 CLAIREMONT MESA BLVD
Practice Address - Street 2:#103
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111
Practice Address - Country:US
Practice Address - Phone:858-277-2277
Practice Address - Fax:858-277-7358
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT11826225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
R62570Medicare UPIN
CAWPT11826AMedicare ID - Type Unspecified