MEDICARE: DR. ERIN CECILIA GUSTAFSON M.D.

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	2083P0901X	Public Health & General Preventive Medicine Physician	152755	CA

General Provider Information

NPI Number	:	1770877060
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ERIN CECILIA GUSTAFSON M.D.

Provider Business Mailing Address
First Line	:	172 W 3RD ST FL 1
Second Line	:
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92415-0010
Country	:	US
Telephone Number	:	909-387-6460
Fax Number	:	909-387-6228

Provider Business Practice Location Address
First Line	:	172 W 3RD ST FL 1
Second Line	:
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92415-6930
Country	:	US
Telephone Number	:	909-387-6460
Fax Number	:	909-387-6228

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

Provider Enumeration Date	:	06/03/2011
Last Update Date	:	10/28/2019

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