Provider Demographics
NPI:1417537259
Name:GUSTAFSON, SHANSHAN ELISSA
Entity Type:Individual
Prefix:
First Name:SHANSHAN
Middle Name:ELISSA
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELISSA
Other - Middle Name:SHANSHAN
Other - Last Name:HEH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:655 WATKINS MILL RD FL 5
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20879-3301
Mailing Address - Country:US
Mailing Address - Phone:240-632-4021
Mailing Address - Fax:
Practice Address - Street 1:655 WATKINS MILL RD FL 5
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20879-3301
Practice Address - Country:US
Practice Address - Phone:240-632-4021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-14
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0097815207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine