Provider Demographics
NPI:1295764405
Name:GUSTAFSON, CAITLIN J (MD)
Entity type:Individual
Prefix:
First Name:CAITLIN
Middle Name:J
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:PO BOX 1047
Mailing Address - Street 2:
Mailing Address - City:MCCALL
Mailing Address - State:ID
Mailing Address - Zip Code:83638-1047
Mailing Address - Country:US
Mailing Address - Phone:208-634-2225
Mailing Address - Fax:208-634-5547
Practice Address - Street 1:211 FOREST ST
Practice Address - Street 2:
Practice Address - City:MCCALL
Practice Address - State:ID
Practice Address - Zip Code:83638
Practice Address - Country:US
Practice Address - Phone:208-634-2225
Practice Address - Fax:208-634-5547
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM9146207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDB6157OtherBC CMMC
ID000010157054OtherBS PLMC
ID76664OtherBC PLMC
ID806631600Medicaid
ID000010157054OtherBS PLMC
ID806631600Medicaid