Healthcare Provider Details

I. General information

NPI: 1194708552
Provider Name (Legal Business Name): CYNTHIA J GUSTAFSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2005
Last Update Date: 01/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 SE MONTEREY RD STE 303
STUART FL
34994-4512
US

IV. Provider business mailing address

1050 SE MONTEREY RD SUITE 400
STUART FL
34994-4512
US

V. Phone/Fax

Practice location:
  • Phone: 772-288-2400
  • Fax: 772-419-0143
Mailing address:
  • Phone: 772-288-2400
  • Fax: 772-419-0155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberME46148
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: