Provider Demographics
NPI:1851310825
Name:GUSTAFSON, GEORGE ALLEN (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:ALLEN
Last Name:GUSTAFSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 WEST LUGONIA AVE. STE. 210
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374
Mailing Address - Country:US
Mailing Address - Phone:909-557-1600
Mailing Address - Fax:909-557-1740
Practice Address - Street 1:1901 WEST LUGONIA AVE. STE. 210
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92374
Practice Address - Country:US
Practice Address - Phone:909-557-1600
Practice Address - Fax:909-557-1740
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2015-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG24086174400000X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA42155Medicare UPIN
CAZZZ28798ZMedicare ID - Type Unspecified
CADR178XMedicare PIN