Provider Demographics
NPI:1851394795
Name:GUSTAFSON, KEITH B (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:B
Last Name:GUSTAFSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:1349 LLEWELLYN AVE
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23517-2266
Mailing Address - Country:US
Mailing Address - Phone:757-962-1114
Mailing Address - Fax:757-962-1114
Practice Address - Street 1:138 S ROSEMONT RD
Practice Address - Street 2:STE 215
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-4336
Practice Address - Country:US
Practice Address - Phone:757-431-9551
Practice Address - Fax:757-431-9663
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101233342207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006986A30Medicare ID - Type Unspecified
VAI27676Medicare UPIN