=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326069055
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KURT JOSEPH GUSTAFSON DPM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/21/2006
-----------------------------------------------------
Last Update Date | 06/21/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 215 S 1ST ST
-----------------------------------------------------
City | LEHIGHTON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18235-2163
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-377-5544
-----------------------------------------------------
Fax | 610-377-6744
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 215 S 1ST ST
-----------------------------------------------------
City | LEHIGHTON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18235-2163
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-377-5544
-----------------------------------------------------
Fax | 610-377-6744
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0131X
-----------------------------------------------------
Taxonomy Name | Foot Surgery Podiatrist
-----------------------------------------------------
License Number | SC004598L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------