Provider Demographics
NPI:1417210790
Name:GUSTAFSON, ALICIA (DO)
Entity Type:Individual
Prefix:
First Name:ALICIA
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 1:1976 TEXAN DR., SUITE 106
Mailing Address - Street 2:
Mailing Address - City:JUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:76247
Mailing Address - Country:US
Mailing Address - Phone:682-212-9020
Mailing Address - Fax:
Practice Address - Street 1:1976 TEXAN DR., SUITE 106
Practice Address - Street 2:
Practice Address - City:JUSTIN
Practice Address - State:TX
Practice Address - Zip Code:76247
Practice Address - Country:US
Practice Address - Phone:682-212-9020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-21
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS9140207QS0010X, 207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine