Healthcare Provider Details

I. General information

NPI: 1467654442
Provider Name (Legal Business Name): BLAKE GUSTAFSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2007
Last Update Date: 05/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4755 OGLETOWN STANTON RD DEPARTMENT OF EMERGENCY MEDICINE
NEWARK DE
19718-2200
US

IV. Provider business mailing address

PO BOX 7529
NEWARK DE
19714-7529
US

V. Phone/Fax

Practice location:
  • Phone: 302-733-1840
  • Fax:
Mailing address:
  • Phone: 302-294-1468
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberC1-0009550
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC1-0009550
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: