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General NPI Number Information
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NPI Number | 1144205345
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Entity Type | Individual
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Provider Name | GARY L. GUSTAFSON D.O.
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Gender | Male
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Dates
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Enumeration Date | 12/09/2005
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Last Update Date | 08/24/2010
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Provider Practice Location Address
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Address Line | 8015 E. 171ST ST.
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City | BELTON
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State | MO
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Zip | 64012
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Country | US
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Telephone | 816-331-0961
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Fax | 816-322-5236
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Provider Business Mailing Address
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Address Line | 8015 E. 171ST ST.
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City | BELTON
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State | MO
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Zip | 64012
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Country | US
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Telephone | 816-331-0961
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Fax | 816-322-5236
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | R8612
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License Number State | MO
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