Healthcare Provider Details

I. General information

NPI: 1629077284
Provider Name (Legal Business Name): GREGORY GUSTAFSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2005
Last Update Date: 05/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4401 FRANCIS LEWIS BLVD
BAYSIDE NY
11361-3002
US

IV. Provider business mailing address

4401 FRANCIS LEWIS BLVD
BAYSIDE NY
11361-3002
US

V. Phone/Fax

Practice location:
  • Phone: 718-423-3355
  • Fax: 718-423-3721
Mailing address:
  • Phone: 718-423-3355
  • Fax: 718-423-3721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number138877
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: