Provider Demographics
NPI:1497745210
Name:GUSTAVSON, ROGER B (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:B
Last Name:GUSTAVSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:890 POPLAR CHURCH RD
Mailing Address - Street 2:SUITE 508
Mailing Address - City:CAMP HILL
Mailing Address - State:PA
Mailing Address - Zip Code:17011-2250
Mailing Address - Country:US
Mailing Address - Phone:717-761-3875
Mailing Address - Fax:717-761-7893
Practice Address - Street 1:890 POPLAR CHURCH RD
Practice Address - Street 2:SUITE 508
Practice Address - City:CAMP HILL
Practice Address - State:PA
Practice Address - Zip Code:17011-2250
Practice Address - Country:US
Practice Address - Phone:717-761-3875
Practice Address - Fax:717-761-7893
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2007-10-19
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
PA012082E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0006517640001Medicaid
PA0006517640001Medicaid
PA103430G7MMedicare PIN