Provider Demographics
NPI:1285701565
Name:GUSTAFSON, STEPHEN E (OD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:E
Last Name:GUSTAFSON
Suffix:
Gender:M
Credentials:OD
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Mailing Address - Street 1:1388 STONEHOLLOW DRIVE
Mailing Address - Street 2:SUITE #1
Mailing Address - City:KINGWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77339-2280
Mailing Address - Country:US
Mailing Address - Phone:281-358-5411
Mailing Address - Fax:281-358-2045
Practice Address - Street 1:1388 STONEHOLLOW DRIVE
Practice Address - Street 2:SUITE #1
Practice Address - City:KINGWOOD
Practice Address - State:TX
Practice Address - Zip Code:77339-2280
Practice Address - Country:US
Practice Address - Phone:281-358-5411
Practice Address - Fax:281-358-2045
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2008-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2482TG152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
0955240001Medicare NSC
T13599Medicare UPIN
00E17KMedicare PIN