Edward Ernest Gustavson, MD

Primary specialty

Developmental - Behavioral Pediatrics PhysicianTaxonomy code 2080P0006X

License

20370 Issued in OK

Practice address

1310 E Boone St
Tahlequah, OK 74464-3338

Phone

(918) 456-7700

Fax

(918) 458-9314

NPI assigned

Jul 4, 2006

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Brookhaven Hospital, LLC

  • Psychiatric Hospital
  • Tulsa, OK
  • NPI 1023064300
  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1151971200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1375056000000",
    "number": "1386674182",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1310 E BOONE ST",
            "city": "TAHLEQUAH",
            "state": "OK",
            "postal_code": "744643338",
            "telephone_number": "918-456-7700",
            "fax_number": "918-458-9314"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1310 E BOONE ST",
            "city": "TAHLEQUAH",
            "state": "OK",
            "postal_code": "744643338",
            "telephone_number": "918-456-7700",
            "fax_number": "918-458-9314"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "GUSTAVSON",
        "first_name": "EDWARD",
        "middle_name": "ERNEST",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-07-04",
        "last_updated": "2013-07-29",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "2080P0006X",
            "taxonomy_group": "",
            "desc": "Pediatrics, Developmental - Behavioral Pediatrics",
            "state": "OK",
            "license": "20370",
            "primary": true
        },
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "OK",
            "license": "20370",
            "primary": false
        },
        {
            "code": "2080N0001X",
            "taxonomy_group": "",
            "desc": "Pediatrics, Neonatal-Perinatal Medicine",
            "state": "OK",
            "license": "20370",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100173510A",
            "state": "OK"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Daxton Thane Grigsby, PA
• Shannon Grimes
• Gritts Wellness Clinic, LLC
• Charity Catrina Gritts, ARNP
• Paula M Guinnip, M.D.
• Gladys Paola Guthrie
• Megan Guthrie, M.S.,CCC-SLP
• Carla Guzic, PHARMD
• Blayke Haggard
• Abby Hahn

• Developmental - Behavioral Pediatrics Physician in Tahlequah, OK
• Providers in Tahlequah, OK by specialty
• Developmental - Behavioral Pediatrics Physician in Oklahoma

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 29, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.