Individual
EDWARD ERNEST GUSTAVSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1310 E BOONE ST, TAHLEQUAH, OK 74464-3338
(918) 456-7700
(918) 458-9314
Mailing address
1310 E BOONE ST, TAHLEQUAH, OK 74464-3338
(918) 456-7700
(918) 458-9314
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
20370
OK
2080N0001X
Neonatal-Perinatal Medicine Physician
20370
OK
2080P0006X
Developmental - Behavioral Pediatrics Physician
Primary
20370
OK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100173510A
—
OK
Enumeration date
07/04/2006
Last updated
07/29/2013
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