MEDICARE: PAUL R GUSTAFSON M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	49003	MA

General Provider Information

NPI Number	:	1265557110
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAUL R GUSTAFSON M.D.

Provider Business Mailing Address
First Line	:	9407 CRANLEIGH CT
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77096-4207
Country	:	US
Telephone Number	:	713-726-9989
Fax Number	:

Provider Business Practice Location Address
First Line	:	9407 CRANLEIGH CT
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77096-4207
Country	:	US
Telephone Number	:	713-726-9989
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/20/2007
Last Update Date	:	07/08/2007

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