Healthcare Provider Details

I. General information

NPI: 1538430178
Provider Name (Legal Business Name): GAY L GUSTAFSON DPM PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2012
Last Update Date: 03/30/2023
Certification Date: 03/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7700 MENAUL BLVD NE STE D
ALBUQUERQUE NM
87110-4616
US

IV. Provider business mailing address

7700 MENAUL BLVD NE STE D
ALBUQUERQUE NM
87110-4616
US

V. Phone/Fax

Practice location:
  • Phone: 505-299-4487
  • Fax: 505-299-4498
Mailing address:
  • Phone: 505-299-4487
  • Fax: 505-299-4498

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number252
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: GAY L GUSTAFSON
Title or Position: OWNER
Credential: DPM
Phone: 505-299-4487