Provider Demographics
NPI:1083840565
Name:GUSTAFSON, CHERYL JANENE (MD)
Entity Type:Individual
Prefix:DR
First Name:CHERYL
Middle Name:JANENE
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 24325
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-0325
Mailing Address - Country:US
Mailing Address - Phone:062-327-5462
Mailing Address - Fax:503-362-8435
Practice Address - Street 1:3216 NE 45TH PL STE 101
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-4028
Practice Address - Country:US
Practice Address - Phone:206-525-1168
Practice Address - Fax:206-525-1169
Is Sole Proprietor?:No
Enumeration Date:2009-06-10
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01075298A207N00000X
WAMD60757392207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2084320Medicaid