Provider Demographics
NPI:1760592984
Name:GUSTAFSON, DOUG ALLEN (ARDMS,RVT,RDCS)
Entity Type:Individual
Prefix:MR
First Name:DOUG
Middle Name:ALLEN
Last Name:GUSTAFSON
Suffix:
Gender:M
Credentials:ARDMS,RVT,RDCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34724 CAPROCK RD
Mailing Address - Street 2:
Mailing Address - City:AGUA DULCE
Mailing Address - State:CA
Mailing Address - Zip Code:91390-5422
Mailing Address - Country:US
Mailing Address - Phone:661-268-0791
Mailing Address - Fax:661-268-0792
Practice Address - Street 1:34724 CAPROCK RD
Practice Address - Street 2:
Practice Address - City:AGUA DULCE
Practice Address - State:CA
Practice Address - Zip Code:91390-5422
Practice Address - Country:US
Practice Address - Phone:661-268-0791
Practice Address - Fax:661-268-0792
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CATG128Medicare ID - Type UnspecifiedPROVIDER NUMBER