Provider Demographics
NPI:1578547543
Name:ZASTROW, CONNIE L (MD)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:L
Last Name:ZASTROW
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 5096
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98227-5096
Mailing Address - Country:US
Mailing Address - Phone:360-788-6063
Mailing Address - Fax:360-788-6817
Practice Address - Street 1:2950 SQUALICUM PKWY
Practice Address - Street 2:SUITE A
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-1857
Practice Address - Country:US
Practice Address - Phone:360-788-6063
Practice Address - Fax:360-788-6817
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2010-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WAMD601508432086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1578547543Medicaid
WA0262756OtherL&I AND CRIME VICTIMS
WA0026ZAOtherREGENCE
WAG8892931Medicare PIN
WA1578547543Medicaid