Healthcare Provider Details

I. General information

NPI: 1336135573
Provider Name (Legal Business Name): KARIN GUSTAFSON D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2005
Last Update Date: 07/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 OGDEN AVE SUITE 120
AURORA IL
60504-5894
US

IV. Provider business mailing address

1256 WATERFORD DRIVE SUITE 230
AURORA IL
60504
US

V. Phone/Fax

Practice location:
  • Phone: 630-375-2852
  • Fax: 630-375-2838
Mailing address:
  • Phone: 630-499-2404
  • Fax: 630-499-2399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036-083067
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: