Provider Demographics
NPI:1255461547
Name:GUSTILO, ORLAND S (MD)
Entity type:Individual
Prefix:
First Name:ORLAND
Middle Name:S
Last Name:GUSTILO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3660 ROME DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-4488
Mailing Address - Country:US
Mailing Address - Phone:765-446-9394
Mailing Address - Fax:765-447-8875
Practice Address - Street 1:3660 ROME DR
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-4488
Practice Address - Country:US
Practice Address - Phone:765-446-9394
Practice Address - Fax:765-447-8875
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010287442084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100086080AMedicaid
IN070920FMedicare ID - Type Unspecified