Basic Information
| Provider Information | |||||||||
| NPI: | 1881771822 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | GUSTAFSON | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2910 CENTRE POINTE DRIVE | ||||||||
| Address2: | 35 121A CHILDRENS HEALTH CARE | ||||||||
| City: | ROSEVILLE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6518552327 | ||||||||
| FaxNumber: | 6518552310 | ||||||||
| Practice Location | |||||||||
| Address1: | 345 NORTH SMITH AVENUE | ||||||||
| Address2: | CHILDRENS HOSPITALS AND CLINICS OF MINNESOTA EMERGENCY | ||||||||
| City: | ST PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512206914 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 207P00000X | 27137 | MN | X | Allopathic & Osteopathic Physicians | Emergency Medicine | 207PP0204X | 27137 | MN | X | Allopathic & Osteopathic Physicians | Emergency Medicine | Pediatric Emergency Medicine | 208000000X | 27137 | MN | X | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0204X | 27137 | MN | X | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine |
No ID Information.