Provider Demographics
NPI:1245976158
Name:GUSTAFSON, CHAD (NRP, IDHS)
Entity type:Individual
Prefix:
First Name:CHAD
Middle Name:
Last Name:GUSTAFSON
Suffix:
Gender:M
Credentials:NRP, IDHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 17TH ST NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20500
Mailing Address - Country:US
Mailing Address - Phone:202-814-6607
Mailing Address - Fax:
Practice Address - Street 1:1650 17TH ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20500
Practice Address - Country:US
Practice Address - Phone:202-814-6607
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-12
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman