Provider Demographics
NPI:1215497045
Name:GUSTAFSON, ANN MARIE (MD)
Entity type:Individual
Prefix:
First Name:ANN
Middle Name:MARIE
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1349 LEXINGTON AVE APT 1EC
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-1514
Mailing Address - Country:US
Mailing Address - Phone:917-733-4740
Mailing Address - Fax:
Practice Address - Street 1:1349 LEXINGTON AVE APT 1EC
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10128-1514
Practice Address - Country:US
Practice Address - Phone:917-733-4740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-20
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3161112084P0800X
NY1131612084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry