Provider Demographics
NPI:1902977861
Name:GUSTAFSON, NOEL STEPHAN (DC)
Entity Type:Individual
Prefix:DR
First Name:NOEL
Middle Name:STEPHAN
Last Name:GUSTAFSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4051 COOPER RIDGE CT SE
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-6462
Mailing Address - Country:US
Mailing Address - Phone:404-284-0888
Mailing Address - Fax:404-284-4067
Practice Address - Street 1:2417 CANDLER RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30032-6410
Practice Address - Country:US
Practice Address - Phone:404-284-0888
Practice Address - Fax:404-284-4067
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA6709111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor