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NPI Code Detail

MEDICARE: DAVID LEOR GUSTAFSON DPT

MEDICARE: DAVID LEOR GUSTAFSON DPT
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
1225100000XPhysical TherapistPT011099GA
2225100000XPhysical TherapistP15717NC

General Provider Information

NPI Number : 1316379308
Entity Type Code : Individual
Provider Name (Legal Business Name) : DAVID LEOR GUSTAFSON DPT
Provider Business Mailing Address
First Line : 8823 PRODUCTION LN
Second Line :
City : OOLTEWAH
State : TN
Zip : 37363-6511
Country : US
Telephone Number : 423-238-7217
Fax Number : 423-362-8684
Provider Business Practice Location Address
First Line : 3935 BRIAN JORDAN PL
Second Line : STE 119
City : HIGH POINT
State : NC
Zip : 27265-8036
Country : US
Telephone Number : 336-885-0440
Fax Number : 336-885-0442
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/01/2013
Last Update Date : 02/28/2017

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Directions to “ DAVID LEOR GUSTAFSON DPT” Practice Location

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