Provider Demographics
NPI:1316379308
Name:GUSTAFSON, DAVID LEOR (DPT)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:LEOR
Last Name:GUSTAFSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8823 PRODUCTION LN
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-6511
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-362-8684
Practice Address - Street 1:3935 BRIAN JORDAN PL
Practice Address - Street 2:STE 119
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27265-8036
Practice Address - Country:US
Practice Address - Phone:336-885-0440
Practice Address - Fax:336-885-0442
Is Sole Proprietor?:No
Enumeration Date:2013-08-01
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT011099225100000X
NCP15717225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist