Provider Demographics
NPI:1467807230
Name:GUSTAFSON, TESHA (OD)
Entity Type:Individual
Prefix:
First Name:TESHA
Middle Name:
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 2ND ST NW
Mailing Address - Street 2:
Mailing Address - City:KENMARE
Mailing Address - State:ND
Mailing Address - Zip Code:58746-7114
Mailing Address - Country:US
Mailing Address - Phone:701-385-4004
Mailing Address - Fax:701-385-4005
Practice Address - Street 1:28 2ND ST NW
Practice Address - Street 2:
Practice Address - City:KENMARE
Practice Address - State:ND
Practice Address - Zip Code:58746-7114
Practice Address - Country:US
Practice Address - Phone:701-385-4004
Practice Address - Fax:701-385-4005
Is Sole Proprietor?:No
Enumeration Date:2016-04-29
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND745152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist