Individual
BRENT LEE GUSTAFSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
N84W16889 MENOMONEE AVE, MENOMONEE FALLS, WI 53051-2810
(262) 251-7500
(262) 532-1396
Mailing address
PO BOX 735044, CHICAGO, IL 60673-5044
(262) 251-7500
(262) 532-1396
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
4301504906
MI
207Q00000X
Family Medicine Physician
Primary
82122
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100242146
—
WI
Enumeration date
06/19/2019
Last updated
09/07/2023
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