Provider Demographics
NPI:1043519184
Name:GUSTAFSON, STEVEN A (DO)
Entity type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:A
Last Name:GUSTAFSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4371 E LOHMAN AVE BLDG 4
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-8255
Mailing Address - Country:US
Mailing Address - Phone:713-791-8718
Mailing Address - Fax:
Practice Address - Street 1:4371 E LOHMAN AVE
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-8255
Practice Address - Country:US
Practice Address - Phone:575-523-5679
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-15
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDO2024-0142204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Multi-Specialty