Provider Demographics
NPI:1790287464
Name:GUSTAFSON, STEFAN ERIK (DPT)
Entity Type:Individual
Prefix:
First Name:STEFAN
Middle Name:ERIK
Last Name:GUSTAFSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33985 MANTA CT
Mailing Address - Street 2:
Mailing Address - City:DANA POINT
Mailing Address - State:CA
Mailing Address - Zip Code:92629-4507
Mailing Address - Country:US
Mailing Address - Phone:608-528-8358
Mailing Address - Fax:
Practice Address - Street 1:23961 CALLE DE LA MAGDALENA STE 119
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-3616
Practice Address - Country:US
Practice Address - Phone:949-837-5111
Practice Address - Fax:949-837-6111
Is Sole Proprietor?:No
Enumeration Date:2018-03-08
Last Update Date:2018-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT294525208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation