Provider Demographics
NPI:1265618136
Name:GUSTIN, STACY ELIZABETH (DO)
Entity type:Individual
Prefix:DR
First Name:STACY
Middle Name:ELIZABETH
Last Name:GUSTIN
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Gender:F
Credentials:DO
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Mailing Address - Street 1:4840 E INDIAN SCHOOL RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-5500
Mailing Address - Country:US
Mailing Address - Phone:480-882-7360
Mailing Address - Fax:602-840-4250
Practice Address - Street 1:4840 E INDIAN SCHOOL RD
Practice Address - Street 2:SUITE 100
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018-5500
Practice Address - Country:US
Practice Address - Phone:480-882-7360
Practice Address - Fax:602-952-9432
Is Sole Proprietor?:No
Enumeration Date:2008-01-10
Last Update Date:2014-09-25
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Provider Licenses
StateLicense IDTaxonomies
AZ4643207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ124486OtherMEDICARE PTAN