Basic Information
Provider Information | |||||||||
NPI: | 1255417853 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CRAIG ALLEN GUSTAFSON MD PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GUSTAFSON | ||||||||
AuthorizedOfficialFirstName: | CRAIG | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 9702421566 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 23176822 | 05 | CO |   | MEDICAID | DB9937 | 01 | CO | RAILROAD MEDICARE | OTHER |