Provider Demographics
NPI:1720055528
Name:GUSTAFSON, THOMAS R (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:R
Last Name:GUSTAFSON
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 1:1 GUTHRIE SQ
Mailing Address - Street 2:
Mailing Address - City:SAYRE
Mailing Address - State:PA
Mailing Address - Zip Code:18840-1625
Mailing Address - Country:US
Mailing Address - Phone:570-888-5858
Mailing Address - Fax:
Practice Address - Street 1:1243 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:PINE CITY
Practice Address - State:NY
Practice Address - Zip Code:14871-9230
Practice Address - Country:US
Practice Address - Phone:607-734-3929
Practice Address - Fax:607-734-0781
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2011-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD042588L207Q00000X
NY186217-1207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012479510001Medicaid
NY01255774Medicaid
NY080173355OtherRR MEDICARE PIN
NYCC8362OtherRR MEDICARE GROUP
NY080173355OtherRR MEDICARE PIN
NY01255774Medicaid