Healthcare Provider Details

I. General information

NPI: 1932197407
Provider Name (Legal Business Name): TERRY JOHN GUSTAFSON OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2005
Last Update Date: 01/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17416 PACIFIC AVE S
SPANAWAY WA
98387-8263
US

IV. Provider business mailing address

17416 PACIFIC AVE SO
SPANAWAY WA
98387-0728
US

V. Phone/Fax

Practice location:
  • Phone: 253-531-1388
  • Fax: 253-531-1460
Mailing address:
  • Phone: 253-531-1388
  • Fax: 253-531-1460

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1084
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: