Provider Demographics
NPI:1558349589
Name:BAUSTIAN, GORDON (MD)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:
Last Name:BAUSTIAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 8TH ST SE
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52401-2143
Mailing Address - Country:US
Mailing Address - Phone:319-398-6170
Mailing Address - Fax:319-398-6466
Practice Address - Street 1:610 8TH ST SE
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52401-2143
Practice Address - Country:US
Practice Address - Phone:319-398-6170
Practice Address - Fax:319-398-6466
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2009-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA22013207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1192997Medicaid
IA01218Medicare ID - Type Unspecified
IAI0923174Medicare PIN
IAA01960Medicare UPIN