Provider Demographics
NPI:1316470255
Name:GUSTAFSON, ERIC (DPM)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:GUSTAFSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6801 DIXIE HWY STE 134
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40258-3952
Mailing Address - Country:US
Mailing Address - Phone:502-447-4500
Mailing Address - Fax:
Practice Address - Street 1:6801 DIXIE HWY STE 134
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40258-3952
Practice Address - Country:US
Practice Address - Phone:502-447-4500
Practice Address - Fax:502-449-0108
Is Sole Proprietor?:No
Enumeration Date:2017-04-07
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY262794213ES0103X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program