Provider Demographics
NPI:1346247632
Name:SHUSTOV, ANDREI R (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDREI
Middle Name:R
Last Name:SHUSTOV
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 EASTLAKE AVENUE E
Mailing Address - Street 2:G3-200
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98109-1023
Mailing Address - Country:US
Mailing Address - Phone:206-288-6739
Mailing Address - Fax:206-288-6473
Practice Address - Street 1:825 EASTLAKE AVENUE E
Practice Address - Street 2:G3-200
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98109-1023
Practice Address - Country:US
Practice Address - Phone:206-288-6739
Practice Address - Fax:206-288-6473
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00042672207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8421596Medicaid
WA8852578Medicare ID - Type Unspecified
WA8421596Medicaid