Provider Demographics
NPI:1467692103
Name:GUSTAVUS FAMILY CLINIC
Entity Type:Organization
Organization Name:GUSTAVUS FAMILY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:L
Authorized Official - Last Name:GUSTAVUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:501-833-0177
Mailing Address - Street 1:7418 N HILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72116-4525
Mailing Address - Country:US
Mailing Address - Phone:501-833-0177
Mailing Address - Fax:501-833-0223
Practice Address - Street 1:7418 N HILLS BLVD
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72116-4525
Practice Address - Country:US
Practice Address - Phone:501-833-0177
Practice Address - Fax:501-833-0223
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARDUK INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-02-20
Last Update Date:2009-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR52054C761OtherBCBS OF AR
AR5C761Medicare PIN
ARC68426Medicare UPIN