EDWARD ERNEST GUSTAVSON (NPI# 1386674182) is a health care provider registered in Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES).
| Nation Provider ID (NPI) | 1386674182 |
| Entity Type | Individual |
| Full Name | EDWARD ERNEST GUSTAVSON |
| Credential | MD |
| Practice Address |
1310 E Boone St Tahlequah OK 74464-3338 |
| Practice Telephone | 9184567700 |
| Practice Fax Number | 9184589314 |
| Mailing Telephone | 9184567700 |
| Mailing Fax Number | 9184589314 |
| Enumeration Date | 2006-07-04 |
| Last Update Date | 2013-07-29 |
| Gender Code | M |
| Is Sole Proprietor | N |
| Primary | Taxonomy Code | Classification | License Number | License State | Taxonomy Group |
|---|---|---|---|---|---|
| N | 208000000X | Pediatrics | 20370 | OK | Allopathic & Osteopathic Physicians |
| N | 2080N0001X |
Pediatrics Specialization: Neonatal-Perinatal Medicine |
20370 | OK | Allopathic & Osteopathic Physicians |
| Y | 2080P0006X |
Pediatrics Specialization: Developmental – Behavioral Pediatrics |
20370 | OK | Allopathic & Osteopathic Physicians |
| State | Issuer | Identifier | Type Code |
|---|---|---|---|
| OK | 100173510A | 05 |
| Street Address |
1310 E BOONE ST |
| City | TAHLEQUAH |
| State | OK |
| Zip Code | 74464-3338 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1376513002 | Northeastern Oklahoma Community Health Centers Inc | Clinic/Center | 1310 E Boone St, Tahlequah, OK 74464-3338 | 2006-01-25 |
| 1235676966 | Kristi Dawn Haney | Nurse Practitioner | 1310 E Boone St, Tahlequah, OK 74464-3338 | 2017-01-19 |
| 1528402898 | Samirah Munir Ashraf | Pediatrics | 1310 E Boone St, Tahlequah, OK 74464-3338 | 2013-04-17 |
| 1558613356 | Angela Lynne Mcconnell | Nurse Practitioner | 1310 E Boone St, Tahlequah, OK 74464-3338 | 2012-10-04 |
| 1407106180 | Gena Powers | Nurse Practitioner | 1310 E Boone St, Tahlequah, OK 74464-3338 | 2012-09-11 |
| 1134326564 | Gary Lynn Gaston | Pediatrics | 1310 E Boone St, Tahlequah, OK 74464-3338 | 2007-06-29 |
| 1720122914 | Naveed Siddique | Pediatrics | 1310 E Boone St, Tahlequah, OK 74464-3338 | 2007-02-19 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1184253403 | Kendall Harris | Student in an Organized Health Care Education/Training Program | 100 Bliss Ave, Tahlequah, OK 74464 | 2020-04-07 |
| 1528609302 | Norma Brightly | Technician | 103 Sequoyah, Tahlequah, OK 74464 | 2019-10-03 |
| 1073175832 | Jody Lynn Dallis | Case Manager/Care Coordinator | Tenkiller Behavioral Services, 27753 S. Welling Rd, Welling, OK 74464 | 2019-07-02 |
| 1184287849 | Perry Jake Proctor | Student in an Organized Health Care Education/Training Program | 1400 E Downing St, Tahlequah, Ok 74464, Tahlequah, OK 74464 | 2019-04-18 |
| 1336657279 | Sidney Sheyenne Kimble | Case Manager/Care Coordinator | 1429 Jack Brown Lane, Tahlequah, OK 74464 | 2018-01-12 |
| 1891225686 | Nichols Bradley Alberty | Orthotist | 1294 East Downing, Suite 3, Tahlequah, OK 74464 | 2017-06-14 |
| 1922549690 | Krystal Easter Ms, Lpc | Counselor | 2201 Oakridge Dr, Tahlequah, OK 74464 | 2017-03-15 |
| 1144777319 | Northeastern Oklahoma Community Health Centers, Inc. | Clinic/Center | 529 N. Oak St., Tahlequah, OK 74464 | 2016-09-06 |
| 1548713456 | Clement Isioma Nwadozi | Optometrist | 3763 Southridge Cir Apt 6, Tahlequah, OK 74464 | 2016-07-27 |
| 1033532635 | Wesley Gragg | Specialist/Technologist | 603 North Grand Avenue, Tahlequah, OK 74464 | 2014-02-03 |
| Find all providers in zip 74464 | ||||
| Taxonomy Code | 2080P0006X |
| Grouping | Allopathic & Osteopathic Physicians |
| Classification | Pediatrics |
| Specialization | Developmental – Behavioral Pediatrics |
| A developmental-behavioral specialist is a pediatrician with special training and experience who aims to foster understanding and promotion of optimal development of children and families through research, education, clinical care and advocacy efforts. This physician assists in the prevention, diagnosis, and management of developmental difficulties and problematic behaviors in children and in the family dysfunctions that compromise children's development. |
| Notes: Source: American Board of Medical Specialties, 2007. www.abms.org [7/1/2007: definition changed, source changed, 3/26/2008: definition corrected] Additional Resources: American Board of Pediatrics, 2007. http://www.abp.org/. Board certification for Medical Doctors (MDs) is provided by the American Board of Pediatrics. |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1336796242 | Foundations Therapy, Pllc | Pediatrics | 3905 N Harrison St, Shawnee, OK 74804-1426 | 2019-08-25 |
| 1285797910 | Willienell H Bryant-pitts | Pediatrics | 216 N Murray St, Helena, OK 73741-1017 | 2006-12-17 |
| 1336194307 | Laurie Ann Kukas | Pediatrics | 1024 Nw 47th St, Ste A, Oklahoma City, OK 73118-6412 | 2006-05-24 |
| 1639783012 | Relfections Behavioral Health | Pediatrics | 502 W Atlanta St, Broken Arrow, OK 74012-7004 | 2020-09-03 |
| 1083231724 | Broken Arrow Pediatric Behavioral Health LLC | Pediatrics | 502 W Atlanta St, Broken Arrow, OK 74012-7004 | 2020-06-29 |
| 1033562202 | Behavioral Pediatrics of Tulsa Plc | Pediatrics | 5110 S Yale Ave, Suite 103, Tulsa, OK 74135-7401 | 2016-07-22 |
| 1154695278 | Sanford World Clinics | Pediatrics | 2502 W Elk Ave, Duncan, OK 73533-1562 | 2012-03-07 |
| 1235403023 | Newborn Specialists of Tulsa, PC | Pediatrics | 1805 E 15th St, Tulsa, OK 74104-4610 | 2012-02-27 |
| 1154632610 | Laurie A. Kukas, D. O. Faap | Pediatrics | 1024 Nw 47th St, Ste A, Oklahoma City, OK 73118-6400 | 2010-06-29 |
| 1760544068 | Daryl Leroy Scurry | Pediatrics | 1515 Ne Lawrie Tatum Rd, Lawton Indian Hospital, Lawton, OK 73507-3002 | 2006-12-14 |
| Find all providers with the same taxonomy | ||||
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| Data Provider | Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES) |
| Jurisdiction | Medicare & Medicaid |
This dataset includes 5.44 million covered health care providers and all health plans and health care clearinghouses, registered with CMA NPPES. Each provider is registered with National Provider Identifier (NPI), full name, status, address, taxonomy, other identifiers, etc.