Provider Demographics
NPI:1336135573
Name:GUSTAFSON, KARIN (DO)
Entity Type:Individual
Prefix:
First Name:KARIN
Middle Name:
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1256 WATERFORD DRIVE
Mailing Address - Street 2:SUITE 230
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60504
Mailing Address - Country:US
Mailing Address - Phone:630-499-2404
Mailing Address - Fax:630-499-2399
Practice Address - Street 1:2020 OGDEN AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-5894
Practice Address - Country:US
Practice Address - Phone:630-375-2852
Practice Address - Fax:630-375-2838
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2017-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-083067207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
L83419Medicare ID - Type Unspecified
E95934Medicare UPIN