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Organization
GUSTAVUS FAMILY CLINIC
Active
Organization
GUSTAVUS FAMILY CLINIC
Active
Parent organization
MARDUK INC
Organization subpart
Yes
Provider details
NPI number
Legal business name
MARDUK INC
Authorized official
DR. JOHN L GUSTAVUS MD (OWNER)
(501) 833-0177
Entity
Organization
Contact information
Practice address
7418 N HILLS BLVD, NORTH LITTLE ROCK, AR 72116-4525
(501) 833-0177
(501) 833-0223
Mailing address
7418 N HILLS BLVD, NORTH LITTLE ROCK, AR 72116-4525
(501) 833-0177
(501) 833-0223
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
52054C761
BCBS OF AR
AR
Enumeration date
02/20/2009
Last updated
03/13/2009
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