Healthcare Provider Details

I. General information

NPI: 1225253693
Provider Name (Legal Business Name): THOMAS PAUL GUSTAFSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 03/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11725 STINSON AVE
CHISAGO CITY MN
55013-9542
US

IV. Provider business mailing address

490 OWASSO HILLS DR
ROSEVILLE MN
55113-2153
US

V. Phone/Fax

Practice location:
  • Phone: 651-257-8499
  • Fax:
Mailing address:
  • Phone: 612-759-3476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS1201X
TaxonomySleep Medicine (Family Medicine) Physician
License Number49732
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number49732
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: