Provider Demographics
NPI:1104951458
Name:GUSTAFSON, RICHARD (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:GUSTAFSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4900 E KENTUCKY AVE
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80246-2365
Mailing Address - Country:US
Mailing Address - Phone:303-756-0101
Mailing Address - Fax:303-756-1408
Practice Address - Street 1:4900 E KENTUCKY AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80246-2365
Practice Address - Country:US
Practice Address - Phone:303-756-0101
Practice Address - Fax:303-756-1408
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO39511208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics