Provider Demographics
NPI:1588606867
Name:GAUSTAD, CHRIS (OD)
Entity Type:Individual
Prefix:
First Name:CHRIS
Middle Name:
Last Name:GAUSTAD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:CHARLES
Other - Last Name:GAUSTAD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1048
Mailing Address - Street 2:
Mailing Address - City:FREELAND
Mailing Address - State:WA
Mailing Address - Zip Code:98249-1048
Mailing Address - Country:US
Mailing Address - Phone:360-331-8424
Mailing Address - Fax:360-331-8425
Practice Address - Street 1:380 SE BARRINGTON DR
Practice Address - Street 2:
Practice Address - City:OAK HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98277-3266
Practice Address - Country:US
Practice Address - Phone:360-675-2235
Practice Address - Fax:360-679-2150
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00003150152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2006765Medicaid
WAGAB27177Medicare PIN
T10602Medicare UPIN
WA2006765Medicaid