=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285701565
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEPHEN E GUSTAFSON OD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/29/2006
-----------------------------------------------------
Last Update Date | 06/04/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1388 STONEHOLLOW DRIVE SUITE #1
-----------------------------------------------------
City | KINGWOOD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77339-2280
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-358-5411
-----------------------------------------------------
Fax | 281-358-2045
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1388 STONEHOLLOW DRIVE SUITE #1
-----------------------------------------------------
City | KINGWOOD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77339-2280
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-358-5411
-----------------------------------------------------
Fax | 281-358-2045
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152WC0802X
-----------------------------------------------------
Taxonomy Name | Corneal and Contact Management Optometrist
-----------------------------------------------------
License Number | 2482TG
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------