Provider Demographics
NPI:1851667000
Name:GUSTAFSON, MARK LEROY (DO)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:LEROY
Last Name:GUSTAFSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:3100 MACCORKLE AVE SE
Mailing Address - Street 2:STE 203
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-1228
Mailing Address - Country:US
Mailing Address - Phone:304-388-1724
Mailing Address - Fax:304-388-1721
Practice Address - Street 1:3110 MACCORKLE AVE SE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1210
Practice Address - Country:US
Practice Address - Phone:304-388-7170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-31
Last Update Date:2016-12-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WV2723207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine