Provider Demographics
NPI:1902800311
Name:SAHLSTROM, GARY B (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:B
Last Name:SAHLSTROM
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 1:4201 NE 66TH AVE.
Mailing Address - Street 2:SUITE 104
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661
Mailing Address - Country:US
Mailing Address - Phone:360-254-4914
Mailing Address - Fax:360-449-4961
Practice Address - Street 1:4816A NE THURSTON WAY
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98662
Practice Address - Country:US
Practice Address - Phone:360-254-4914
Practice Address - Fax:360-449-4961
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000173982085R0202X
ORMD115872085R0202X
CAG304182085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8239204Medicaid
682404Medicare ID - Type Unspecified
WA8239204Medicaid