Provider Demographics
NPI:1295035863
Name:GUSTAFSON, TRACY LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:LEE
Last Name:GUSTAFSON
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Gender:M
Credentials:MD
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Mailing Address - Street 1:151 RAINBOW DR
Mailing Address - Street 2:APT #5152
Mailing Address - City:LIVINGSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77399-1571
Mailing Address - Country:US
Mailing Address - Phone:936-933-9593
Mailing Address - Fax:281-715-3202
Practice Address - Street 1:151 RAINBOW DR
Practice Address - Street 2:APT #5152
Practice Address - City:LIVINGSTON
Practice Address - State:TX
Practice Address - Zip Code:77399-1571
Practice Address - Country:US
Practice Address - Phone:936-933-9593
Practice Address - Fax:281-715-3202
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-28
Last Update Date:2014-04-13
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Provider Licenses
StateLicense IDTaxonomies
TXG2143208000000X, 2083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine