Provider Demographics
NPI:1205817871
Name:GUSTAFSON, DAVID R (DO)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:R
Last Name:GUSTAFSON
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 1:3507 SHADY BEND DR
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64052-2860
Mailing Address - Country:US
Mailing Address - Phone:816-651-8631
Mailing Address - Fax:
Practice Address - Street 1:3507 SHADY BEND DR
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64052-2860
Practice Address - Country:US
Practice Address - Phone:816-651-8631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2011-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR9B87207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOC50437Medicare UPIN