Provider Demographics
NPI:1932197407
Name:GUSTAFSON, TERRY JOHN (OD)
Entity type:Individual
Prefix:DR
First Name:TERRY
Middle Name:JOHN
Last Name:GUSTAFSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17416 PACIFIC AVE SO
Mailing Address - Street 2:
Mailing Address - City:SPANAWAY
Mailing Address - State:WA
Mailing Address - Zip Code:98387-0728
Mailing Address - Country:US
Mailing Address - Phone:253-531-1388
Mailing Address - Fax:253-531-1460
Practice Address - Street 1:17416 PACIFIC AVE S
Practice Address - Street 2:
Practice Address - City:SPANAWAY
Practice Address - State:WA
Practice Address - Zip Code:98387-8263
Practice Address - Country:US
Practice Address - Phone:253-531-1388
Practice Address - Fax:253-531-1460
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-10
Last Update Date:2009-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1084152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2008704Medicaid
WA22875OtherDEPT OF L & I
WA0680660001Medicare NSC
001001124Medicare ID - Type Unspecified
WA2008704Medicaid