Provider Demographics
NPI:1346304284
Name:CHAMUSCO, ROGER S (MD)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:S
Last Name:CHAMUSCO
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:PO BOX 34584
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1584
Mailing Address - Country:US
Mailing Address - Phone:509-241-7349
Mailing Address - Fax:509-241-7628
Practice Address - Street 1:209 MARTIN LUTHER KING JR WAY
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4265
Practice Address - Country:US
Practice Address - Phone:253-596-3370
Practice Address - Fax:253-596-3713
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00017988207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8204752Medicaid
WAG001051032Medicare PIN
WA8204752Medicaid
WA060059627Medicare PIN
WAC83187Medicare UPIN
WAG8872265Medicare PIN
WAG8871500Medicare PIN