Healthcare Provider Details

I. General information

NPI: 1003836016
Provider Name (Legal Business Name): JOHN CHARLES GUSTAFSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2795 LOMA VISTA RD
VENTURA CA
93003-1544
US

IV. Provider business mailing address

2795 LOMA VISTA RD
VENTURA CA
93003-1544
US

V. Phone/Fax

Practice location:
  • Phone: 805-643-8695
  • Fax: 805-643-2087
Mailing address:
  • Phone: 805-643-8695
  • Fax: 805-643-2087

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberG36782
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: