Provider Demographics
NPI:1326069055
Name:GUSTAFSON, KURT JOSEPH (DPM)
Entity Type:Individual
Prefix:
First Name:KURT
Middle Name:JOSEPH
Last Name:GUSTAFSON
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 1:215 S 1ST ST
Mailing Address - Street 2:
Mailing Address - City:LEHIGHTON
Mailing Address - State:PA
Mailing Address - Zip Code:18235-2163
Mailing Address - Country:US
Mailing Address - Phone:610-377-5544
Mailing Address - Fax:610-377-6744
Practice Address - Street 1:215 S 1ST ST
Practice Address - Street 2:
Practice Address - City:LEHIGHTON
Practice Address - State:PA
Practice Address - Zip Code:18235-2163
Practice Address - Country:US
Practice Address - Phone:610-377-5544
Practice Address - Fax:610-377-6744
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC004598L213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0008247770003Medicaid
PA815699Other1ST PRIORITY
PA480033403OtherRAILROAD MEDICARE
PA50000307OtherBLUE CROSS
PA2811707OtherAETNA NO
PA80426OtherGEISINGER
PA043017E7ZMedicare PIN
PA0008247770003Medicaid