Individual
DR. BLAKE GUSTAFSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
4755 OGLETOWN STANTON RD, DEPARTMENT OF EMERGENCY MEDICINE, NEWARK, DE 19718-2200
(302) 733-1840
Mailing address
PO BOX 7529, NEWARK, DE 19714-7529
(302) 294-1468
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
Primary
C1-0009550
DE
207Q00000X
Family Medicine Physician
C1-0009550
DE
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
C1-0009550
STATE LICENSE
DE
Enumeration date
06/01/2007
Last updated
05/10/2013
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