Provider Demographics
NPI:1538182118
Name:GUSTAVSON, ANDREW ROGER (MD)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:ROGER
Last Name:GUSTAVSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 5478
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70302-5478
Mailing Address - Country:US
Mailing Address - Phone:985-493-3090
Mailing Address - Fax:985-493-3091
Practice Address - Street 1:604 N ACADIA RD
Practice Address - Street 2:SUITE 411
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-4897
Practice Address - Country:US
Practice Address - Phone:985-493-3090
Practice Address - Fax:985-493-3091
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2014-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2048762084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2169971Medicaid
CAH59775Medicare UPIN
LA4Q634Medicare PIN
LA2169971Medicaid