Provider Demographics
NPI:1770559635
Name:GUSTAVUS, JOHN L (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:L
Last Name:GUSTAVUS
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 1:7418 NORTH HILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72116-7026
Mailing Address - Country:US
Mailing Address - Phone:501-833-0177
Mailing Address - Fax:501-833-0223
Practice Address - Street 1:7418 NORTH HILLS BLVD
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72116-7026
Practice Address - Country:US
Practice Address - Phone:501-833-0177
Practice Address - Fax:501-833-0223
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC4200207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR106636001Medicaid
ARC-4200OtherAR. MEDICIAL LICENSE NUMB
ARC68426Medicare UPIN
AR52054Medicare ID - Type UnspecifiedMEDICARE NUMBER
52054C761Medicare PIN