MEDICARE: DR. MICHELLE GUSTIN OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	2624	WI

General Provider Information

NPI Number	:	1336106939
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHELLE GUSTIN OD

Provider Business Mailing Address
First Line	:	418 PATRICIA LN
Second Line	:
City	:	WRIGHTSTOWN
State	:	WI
Zip	:	54180-1207
Country	:	US
Telephone Number	:	920-532-0537
Fax Number	:

Provider Business Practice Location Address
First Line	:	2158 W MASON ST
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54303-4705
Country	:	US
Telephone Number	:	920-490-9860
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/27/2006
Last Update Date	:	01/03/2008

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