Provider Demographics
NPI:1336106939
Name:GUSTIN, MICHELLE (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:
Last Name:GUSTIN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:418 PATRICIA LN
Mailing Address - Street 2:
Mailing Address - City:WRIGHTSTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:54180-1207
Mailing Address - Country:US
Mailing Address - Phone:920-532-0537
Mailing Address - Fax:
Practice Address - Street 1:2158 W MASON ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-4705
Practice Address - Country:US
Practice Address - Phone:920-490-9860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2624152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U60178Medicare UPIN