Provider Demographics
NPI:1447222765
Name:GUSTAFSON, KRISTIN A (DO)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:A
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 1:25 S 9TH ST FL 1
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4408
Mailing Address - Country:US
Mailing Address - Phone:215-955-1200
Mailing Address - Fax:215-923-6808
Practice Address - Street 1:25 S 9TH ST FL 1
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107
Practice Address - Country:US
Practice Address - Phone:215-955-1200
Practice Address - Fax:215-923-6808
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMD225827208100000X
PAOS014841208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102334750Medicaid