Provider Demographics
NPI:1497726574
Name:GUSTAFSON, JILL ELIZABETH (MD)
Entity Type:Individual
Prefix:DR
First Name:JILL
Middle Name:ELIZABETH
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5680 DOROTHY WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92115-2307
Mailing Address - Country:US
Mailing Address - Phone:619-265-9204
Mailing Address - Fax:
Practice Address - Street 1:5680 DOROTHY WAY
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92115-2307
Practice Address - Country:US
Practice Address - Phone:619-265-9204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-27
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG72927208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics