MEDICARE: ERIC GUSTAFSON DPM

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	213ES0103X	Foot & Ankle Surgery Podiatrist	262794	KY
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1316470255
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERIC GUSTAFSON DPM

Provider Business Mailing Address
First Line	:	6801 DIXIE HWY STE 134
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40258-3952
Country	:	US
Telephone Number	:	502-447-4500
Fax Number	:

Provider Business Practice Location Address
First Line	:	6801 DIXIE HWY STE 134
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40258-3952
Country	:	US
Telephone Number	:	502-447-4500
Fax Number	:	502-449-0108

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

Provider Enumeration Date	:	04/07/2017
Last Update Date	:	10/07/2021

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Directions to “ ERIC GUSTAFSON DPM” Practice Location

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