Provider Demographics
NPI:1760415368
Name:WUSTRACK, KARL OTTO (MD)
Entity Type:Individual
Prefix:DR
First Name:KARL
Middle Name:OTTO
Last Name:WUSTRACK
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 1:1830 BLANKENSHIP RD
Mailing Address - Street 2:#100
Mailing Address - City:WEST LINN
Mailing Address - State:OR
Mailing Address - Zip Code:97068-4181
Mailing Address - Country:US
Mailing Address - Phone:503-655-9727
Mailing Address - Fax:503-655-9865
Practice Address - Street 1:1830 BLANKENSHIP RD
Practice Address - Street 2:#100
Practice Address - City:WEST LINN
Practice Address - State:OR
Practice Address - Zip Code:97068-4181
Practice Address - Country:US
Practice Address - Phone:503-655-9727
Practice Address - Fax:503-655-9865
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD08363174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist