Healthcare Provider Details

I. General information

NPI: 1114919420
Provider Name (Legal Business Name): GARARD MELVIN GUSTAFSON O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 05/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 MILTON WAY
MILTON WA
98354-8800
US

IV. Provider business mailing address

101 MILTON WAY
MILTON WA
98354-8800
US

V. Phone/Fax

Practice location:
  • Phone: 253-922-0333
  • Fax: 253-922-7322
Mailing address:
  • Phone: 253-922-0333
  • Fax: 253-922-7322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOD00000938
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: