Provider Demographics
NPI:1386674182
Name:GUSTAVSON, EDWARD ERNEST (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:ERNEST
Last Name:GUSTAVSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 E BOONE ST
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-3338
Mailing Address - Country:US
Mailing Address - Phone:918-456-7700
Mailing Address - Fax:918-458-9314
Practice Address - Street 1:1310 E BOONE ST
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-3338
Practice Address - Country:US
Practice Address - Phone:918-456-7700
Practice Address - Fax:918-458-9314
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2013-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK203702080P0006X, 208000000X, 2080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100173510AMedicaid
B58270Medicare UPIN
243531107Medicare ID - Type Unspecified