Provider Demographics
NPI:1740494848
Name:GUSTIN, LAWRENCE MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:MICHAEL
Last Name:GUSTIN
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 1:6302 EAGLEBROOK AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33625-1514
Mailing Address - Country:US
Mailing Address - Phone:813-968-8330
Mailing Address - Fax:
Practice Address - Street 1:6302 EAGLEBROOK AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33625-1514
Practice Address - Country:US
Practice Address - Phone:813-968-8330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME47296208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics