Provider Demographics
NPI:1205663234
Name:GUSTOVIC, TREVOR ISAAC
Entity type:Individual
Prefix:
First Name:TREVOR
Middle Name:ISAAC
Last Name:GUSTOVIC
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1762 MCCOLLUM RD
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44509-2131
Mailing Address - Country:US
Mailing Address - Phone:330-519-3399
Mailing Address - Fax:
Practice Address - Street 1:1762 MCCOLLUM RD
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44509-2131
Practice Address - Country:US
Practice Address - Phone:330-519-3399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-14
Last Update Date:2024-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHJTU4671347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle