Provider Demographics
NPI:1447448360
Name:GUSTAFSON, ALTON J (DC)
Entity type:Individual
Prefix:DR
First Name:ALTON
Middle Name:J
Last Name:GUSTAFSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 E TARPON AVE
Mailing Address - Street 2:
Mailing Address - City:TARPON SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34689-3449
Mailing Address - Country:US
Mailing Address - Phone:727-942-1618
Mailing Address - Fax:
Practice Address - Street 1:23 E TARPON AVE
Practice Address - Street 2:
Practice Address - City:TARPON SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34689-3449
Practice Address - Country:US
Practice Address - Phone:727-942-1618
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-04
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1469111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL89628OtherBCBS
FL89628Medicare PIN