Healthcare Provider Details

I. General information

NPI: 1295764405
Provider Name (Legal Business Name): CAITLIN J. GUSTAFSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2006
Last Update Date: 08/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 FOREST ST
MCCALL ID
83638
US

IV. Provider business mailing address

PO BOX 1047
MCCALL ID
83638-1047
US

V. Phone/Fax

Practice location:
  • Phone: 208-634-2225
  • Fax: 208-634-5547
Mailing address:
  • Phone: 208-634-2225
  • Fax: 208-634-5547

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM9146
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: