Provider Demographics
NPI:1578802054
Name:GUSTAFSON, JEAN A (MD)
Entity Type:Individual
Prefix:DR
First Name:JEAN
Middle Name:A
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 1:17 THALIA ST
Mailing Address - Street 2:
Mailing Address - City:MILL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94941-2020
Mailing Address - Country:US
Mailing Address - Phone:415-388-7144
Mailing Address - Fax:
Practice Address - Street 1:17 THALIA ST
Practice Address - Street 2:
Practice Address - City:MILL VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94941-2020
Practice Address - Country:US
Practice Address - Phone:415-388-7144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-04
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA042354208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A1423540Medicare PIN
CAFO9212Medicare UPIN