Provider Demographics
NPI:1770511305
Name:GUSTAFSON, PAULA ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:PAULA
Middle Name:ANN
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 1:3625 WOODFIELD PL
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47203-1230
Mailing Address - Country:US
Mailing Address - Phone:812-379-4382
Mailing Address - Fax:
Practice Address - Street 1:30 W RAMPART ST
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:IN
Practice Address - Zip Code:46176-8897
Practice Address - Country:US
Practice Address - Phone:317-398-7337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01044150A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200141250AMedicaid
253400AMedicare PIN
IN200141250AMedicaid