Basic Information
| Provider Information | |||||||||
| NPI: | 1013093517 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUSTAFSON | ||||||||
| FirstName: | CRAIG | ||||||||
| MiddleName: | ALLEN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6971 | ||||||||
| Address2: | |||||||||
| City: | LINCOLN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 685060971 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024867020 | ||||||||
| FaxNumber: | 4024346037 | ||||||||
| Practice Location | |||||||||
| Address1: | 2478 PATTERSON RD | ||||||||
| Address2: | SUITE 27 | ||||||||
| City: | GRAND JUNCTION | ||||||||
| State: | CO | ||||||||
| PostalCode: | 815051266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702421566 | ||||||||
| FaxNumber: | 9702630134 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2006 | ||||||||
| LastUpdateDate: | 01/31/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 41250 | CO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00141399 | 01 | CO | RAILROAD MEDICARE | OTHER | 02081334 | 05 | CO | MEDICAID |