Provider Demographics
NPI:1306919931
Name:GUSTAFSON, MARK CHARLES (DC)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:CHARLES
Last Name:GUSTAFSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3916 W 113TH ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55437-3503
Mailing Address - Country:US
Mailing Address - Phone:612-709-3104
Mailing Address - Fax:952-884-0852
Practice Address - Street 1:3916 W 113TH ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55437-3503
Practice Address - Country:US
Practice Address - Phone:612-709-3104
Practice Address - Fax:952-884-0852
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2493111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor