Provider Demographics
NPI:1467427682
Name:GUSTAVISON, DAVID KEVIN (DO)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:KEVIN
Last Name:GUSTAVISON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1447 N HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48602-4727
Mailing Address - Country:US
Mailing Address - Phone:989-583-4401
Mailing Address - Fax:989-583-4409
Practice Address - Street 1:900 COOPER AVE
Practice Address - Street 2:SUITE 4400
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-5182
Practice Address - Country:US
Practice Address - Phone:989-583-4401
Practice Address - Fax:989-583-4409
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2014-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101010467207Q00000X, 2083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3508260Medicaid
MIM65410018Medicare PIN
MIE40412Medicare UPIN