Healthcare Provider Details

I. General information

NPI: 1023271418
Provider Name (Legal Business Name): JENNIFER ANN GUSTAFSON O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2008
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 S HUNTINGTON AVE
BOSTON MA
02130-4817
US

IV. Provider business mailing address

150 S HUNTINGTON AVE # 8B-52
BOSTON MA
02130-4817
US

V. Phone/Fax

Practice location:
  • Phone: 857-364-5543
  • Fax:
Mailing address:
  • Phone: 857-364-5543
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberVUT 007353
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number007353
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number007353
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: