Provider Demographics
NPI:1689669483
Name:GUSTAFSON, GEORGE C (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:C
Last Name:GUSTAFSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1400 E BOULDER ST
Mailing Address - Street 2:STE 700
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-5533
Mailing Address - Country:US
Mailing Address - Phone:719-365-9950
Mailing Address - Fax:719-365-9969
Practice Address - Street 1:1400 E BOULDER ST
Practice Address - Street 2:STE 700
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5533
Practice Address - Country:US
Practice Address - Phone:719-635-7172
Practice Address - Fax:719-444-3759
Is Sole Proprietor?:No
Enumeration Date:2005-09-18
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO43485207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC810432Medicare PIN
COC41110Medicare UPIN
CO802502Medicare ID - Type Unspecified