Provider Demographics
NPI:1528033644
Name:GUSTAFSON, PAUL T (DO)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:T
Last Name:GUSTAFSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7100 COMMERCE WAY
Mailing Address - Street 2:SUITE 180
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-2829
Mailing Address - Country:US
Mailing Address - Phone:615-465-7000
Mailing Address - Fax:
Practice Address - Street 1:196 ARROWHEAD DR
Practice Address - Street 2:STE 9
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930-8752
Practice Address - Country:US
Practice Address - Phone:307-783-8280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYTL#656208600000X
IA2894208600000X
MI5101015864208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY314100OtherBCBS
WYW20714Medicare PIN
WYP00451973Medicare PIN
F96033Medicare UPIN