Provider Demographics
NPI:1851313415
Name:GUSTAFSON, BRUCE (OD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:GUSTAFSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1575 20TH ST NW STE 101
Mailing Address - Street 2:
Mailing Address - City:FARIBAULT
Mailing Address - State:MN
Mailing Address - Zip Code:55021-2931
Mailing Address - Country:US
Mailing Address - Phone:507-332-9900
Mailing Address - Fax:507-332-6800
Practice Address - Street 1:1575 20TH ST NW STE 101
Practice Address - Street 2:
Practice Address - City:FARIBAULT
Practice Address - State:MN
Practice Address - Zip Code:55021-2931
Practice Address - Country:US
Practice Address - Phone:507-332-9900
Practice Address - Fax:507-332-6800
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1651152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNP00080005OtherRAILROAD MEDICARE
MNP00080005OtherRAILROAD MEDICARE
MN5138890001Medicare NSC
MNC03331Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER