Provider Demographics
NPI:1912982620
Name:GUSTAFSON, COREY GERALD (DO)
Entity Type:Individual
Prefix:DR
First Name:COREY
Middle Name:GERALD
Last Name:GUSTAFSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4067 LADERA VISTA RD
Mailing Address - Street 2:
Mailing Address - City:FALLBROOK
Mailing Address - State:CA
Mailing Address - Zip Code:92028-9433
Mailing Address - Country:US
Mailing Address - Phone:757-513-5594
Mailing Address - Fax:
Practice Address - Street 1:4067 LADERA VISTA RD
Practice Address - Street 2:
Practice Address - City:FALLBROOK
Practice Address - State:CA
Practice Address - Zip Code:92028-9433
Practice Address - Country:US
Practice Address - Phone:757-513-5594
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2015-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A13551207P00000X
VA0102201624207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine