Provider Demographics
NPI:1275583551
Name:GUSTAFSON, JON M (MD)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:M
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 1:7009 NAPLES WAY
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72916-8701
Mailing Address - Country:US
Mailing Address - Phone:479-431-7234
Mailing Address - Fax:844-454-8351
Practice Address - Street 1:320 N GREENWOOD AVE
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72901-3454
Practice Address - Country:US
Practice Address - Phone:479-434-2743
Practice Address - Fax:844-454-8351
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY292642084N0400X
ARE-54592084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200126290AMedicaid
AR167300001Medicaid
OK200126290AMedicaid
KY64092646Medicaid
AR5H079Medicare PIN
AR167300001Medicaid
KY000000370088OtherBCBS KY