Provider Demographics
NPI:1285669093
Name:GUSTAFSON, THOMAS CARL (DO)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:CARL
Last Name:GUSTAFSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 NW MARKET ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98107-5225
Mailing Address - Country:US
Mailing Address - Phone:206-782-0500
Mailing Address - Fax:206-782-0502
Practice Address - Street 1:1717 NW MARKET ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98107-5225
Practice Address - Country:US
Practice Address - Phone:206-782-0500
Practice Address - Fax:206-782-0502
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00001187207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1046325Medicaid
WA1046325Medicaid
WAGAB20109Medicare PIN