Provider Demographics
NPI:1629077284
Name:GUSTAFSON, GREGORY (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:GUSTAFSON
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 1:4401 FRANCIS LEWIS BLVD
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-3002
Mailing Address - Country:US
Mailing Address - Phone:718-423-3355
Mailing Address - Fax:718-423-3721
Practice Address - Street 1:4401 FRANCIS LEWIS BLVD
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-3002
Practice Address - Country:US
Practice Address - Phone:718-423-3355
Practice Address - Fax:718-423-3721
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2011-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY138877207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00827358Medicaid
05439QMedicare ID - Type Unspecified
NY00827358Medicaid
NYG400033081Medicare PIN