Provider Demographics
NPI:1689746125
Name:GUSTAFSON, FRANK WARREN (RPT)
Entity Type:Individual
Prefix:MR
First Name:FRANK
Middle Name:WARREN
Last Name:GUSTAFSON
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45240 CLUB DRIVE
Mailing Address - Street 2:
Mailing Address - City:INDIAN WELLS
Mailing Address - State:CA
Mailing Address - Zip Code:92210
Mailing Address - Country:US
Mailing Address - Phone:760-200-3322
Mailing Address - Fax:760-200-3323
Practice Address - Street 1:45240 CLUB DRIVE
Practice Address - Street 2:
Practice Address - City:INDIAN WELLS
Practice Address - State:CA
Practice Address - Zip Code:92210
Practice Address - Country:US
Practice Address - Phone:760-200-3322
Practice Address - Fax:760-200-3323
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT14299225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OPT142990OtherBLUE SHIELD
CAOPT142990Medicare ID - Type Unspecified