Healthcare Provider Details

I. General information

NPI: 1346247632
Provider Name (Legal Business Name): ANDREI R SHUSTOV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2005
Last Update Date: 05/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 EASTLAKE AVENUE E G3-200
SEATTLE WA
98109-1023
US

IV. Provider business mailing address

825 EASTLAKE AVENUE E G3-200
SEATTLE WA
98109-1023
US

V. Phone/Fax

Practice location:
  • Phone: 206-288-6739
  • Fax: 206-288-6473
Mailing address:
  • Phone: 206-288-6739
  • Fax: 206-288-6473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberMD00042672
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: