Healthcare Provider Details

I. General information

NPI: 1093775199
Provider Name (Legal Business Name): GARY S GUSTAFSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 02/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44378 DEQUINDRE RD STERLING HEIGHTS
STERLING HEIGHTS MI
48314-1003
US

IV. Provider business mailing address

44378 DEQUINDRE RD STERLING HEIGHTS
STERLING HEIGHTS MI
48314-1003
US

V. Phone/Fax

Practice location:
  • Phone: 248-964-3070
  • Fax: 248-964-0057
Mailing address:
  • Phone: 248-964-3070
  • Fax: 248-964-0057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number4301046424
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: