Healthcare Provider Details

I. General information

NPI: 1144225855
Provider Name (Legal Business Name): KENNETH GUSTKE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2005
Last Update Date: 05/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13020 N TELECOM PKWY
TEMPLE TERRACE FL
33637-0925
US

IV. Provider business mailing address

13020 N TELECOM PKWY
TEMPLE TERRACE FL
33637-0925
US

V. Phone/Fax

Practice location:
  • Phone: 813-978-9700
  • Fax: 813-558-6129
Mailing address:
  • Phone: 813-978-9700
  • Fax: 813-972-5055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License NumberME38723
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberME38723
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: