Provider Demographics
NPI:1861441818
Name:GUSTAFSON, DWANE R (OD)
Entity Type:Individual
Prefix:DR
First Name:DWANE
Middle Name:R
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 1:1801 19TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:WILLMAR
Mailing Address - State:MN
Mailing Address - Zip Code:56201-4946
Mailing Address - Country:US
Mailing Address - Phone:320-235-2020
Mailing Address - Fax:320-214-5761
Practice Address - Street 1:1801 19TH AVE SW
Practice Address - Street 2:
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201-4946
Practice Address - Country:US
Practice Address - Phone:320-235-2020
Practice Address - Fax:320-214-5761
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1514152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNT65563Medicare UPIN