Provider Demographics
NPI:1245972645
Name:GUSTAFSON, LISA MARIE (MD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:MARIE
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 W MELROSE ST APT 3H
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-3790
Mailing Address - Country:US
Mailing Address - Phone:248-563-7744
Mailing Address - Fax:
Practice Address - Street 1:520 W MELROSE ST APT 3H
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-3790
Practice Address - Country:US
Practice Address - Phone:248-563-7744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-07
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.079920207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology