Individual
L MARK GUSTAFSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
150 CLINIC AVE, SUITE 201, CARROLLTON, GA 30117-4401
(770) 832-1488
Mailing address
150 CLINIC AVE, SUITE 201, CARROLLTON, GA 30117-4401
(770) 832-1488
Taxonomy
Speciality
Code
Description
License number
State
207Y00000X
Otolaryngology Physician
Primary
049795
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00906463B
—
GA
05
—
00906463C
—
GA
01
—
841043
BLUE CROSS CLUE SHIELD
GA
Enumeration date
06/11/2006
Last updated
07/18/2022
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