Provider Demographics
NPI:1821213612
Name:THOMAS C GUSTAFSON
Entity Type:Organization
Organization Name:THOMAS C GUSTAFSON
Other - Org Name:MARKET STREET CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:CARL
Authorized Official - Last Name:GUSTAFSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:206-782-0500
Mailing Address - Street 1:1717 NW MARKET ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98107-5225
Mailing Address - Country:US
Mailing Address - Phone:206-782-0500
Mailing Address - Fax:206-782-0502
Practice Address - Street 1:1717 NW MARKET ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98107-5225
Practice Address - Country:US
Practice Address - Phone:206-782-0500
Practice Address - Fax:206-782-0502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00001187208D00000X
WAAP30007148363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9647421Medicaid
WA1046325Medicaid
WA1046325Medicaid
WAB18175Medicare UPIN
WAGAB20109Medicare ID - Type UnspecifiedDR. GUSTAFSON'S MEDICARE