Provider Demographics
NPI:1407272974
Name:GUSTAFSON, JON MONTGOMERY (DVM)
Entity type:Individual
Prefix:DR
First Name:JON
Middle Name:MONTGOMERY
Last Name:GUSTAFSON
Suffix:
Gender:M
Credentials:DVM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4636 55TH ST
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-3005
Mailing Address - Country:US
Mailing Address - Phone:303-530-2500
Mailing Address - Fax:303-530-2885
Practice Address - Street 1:4636 55TH ST
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-3005
Practice Address - Country:US
Practice Address - Phone:303-530-2500
Practice Address - Fax:303-530-2885
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-08
Last Update Date:2014-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3822174M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174M00000XOther Service ProvidersVeterinarian