Healthcare Provider Details

I. General information

NPI: 1770418030
Provider Name (Legal Business Name): GREGORY ROBERT GUSTAVSON APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: GREG ROBERT GUSTAVSON APRN

II. Dates (important events)

Enumeration Date: 06/16/2026
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 MANSFIELD AVE
WILLIMANTIC CT
06226-2040
US

IV. Provider business mailing address

5 BEAUDET TER
COLUMBIA CT
06237-1404
US

V. Phone/Fax

Practice location:
  • Phone: 860-456-9116
  • Fax:
Mailing address:
  • Phone: 860-617-0730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number12.017664
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: