Provider Demographics
NPI:1851702823
Name:GUSAK, DAVOR (DO)
Entity Type:Individual
Prefix:
First Name:DAVOR
Middle Name:
Last Name:GUSAK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 N EAST AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-1753
Mailing Address - Country:US
Mailing Address - Phone:517-788-4800
Mailing Address - Fax:517-817-7050
Practice Address - Street 1:205 N EAST AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1753
Practice Address - Country:US
Practice Address - Phone:517-788-4800
Practice Address - Fax:517-817-7050
Is Sole Proprietor?:No
Enumeration Date:2014-05-13
Last Update Date:2018-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02005314A207P00000X
MI5101020939390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine