Provider Demographics
NPI:1730216433
Name:THOMAS GUSTAFERRO MD INC
Entity type:Organization
Organization Name:THOMAS GUSTAFERRO MD INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:GUSTAFERRO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:440-543-2200
Mailing Address - Street 1:17747 CHILLICOTHE RD
Mailing Address - Street 2:STE 106
Mailing Address - City:CHAGRIN FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44023-4739
Mailing Address - Country:US
Mailing Address - Phone:440-543-2200
Mailing Address - Fax:
Practice Address - Street 1:17747 CHILLICOTHE RD
Practice Address - Street 2:STE 106
Practice Address - City:CHAGRIN FALLS
Practice Address - State:OH
Practice Address - Zip Code:44023-4739
Practice Address - Country:US
Practice Address - Phone:440-543-2200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9297731Medicare PIN