1497061352 NPI number — MR. DANIEL JAMES GUSTIN PHARM D

Table of content: MR. DANIEL JAMES GUSTIN PHARM D (NPI 1497061352)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497061352 NPI number — MR. DANIEL JAMES GUSTIN PHARM D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GUSTIN
Provider First Name:
DANIEL
Provider Middle Name:
JAMES
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PHARM D
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497061352
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/29/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1109 LOMBARDI AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREEN BAY
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54304
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-499-6004
Provider Business Mailing Address Fax Number:
920-499-7959

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1109 LOMBARDI AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREEN BAY
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54304
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-499-6004
Provider Business Practice Location Address Fax Number:
920-499-7959
Provider Enumeration Date:
08/28/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  15396-40 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com