Provider Demographics
NPI:1053340885
Name:QUDDUSI, SHAISTA (MD)
Entity type:Individual
Prefix:DR
First Name:SHAISTA
Middle Name:
Last Name:QUDDUSI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHAISTA
Other - Middle Name:
Other - Last Name:ANSARI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:700 S 320TH ST,
Mailing Address - Street 2:ADVANCED DIABETES & ENDOCRINE CARE SUITE D
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003
Mailing Address - Country:US
Mailing Address - Phone:253-880-1029
Mailing Address - Fax:
Practice Address - Street 1:700 S 320TH ST
Practice Address - Street 2:SUITE D
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-4691
Practice Address - Country:US
Practice Address - Phone:253-880-1029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-02
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00032808207R00000X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8228041Medicaid
WA04301438OtherECFMG
WA8904723OtherCRIME VICTIMS
WA8940048OtherCRIME VICTIMS
WAP00181501OtherRAILROAD
WA0195405OtherL & I
WA0205416OtherL & I
WA0205416OtherL & I
WA04301438OtherECFMG
WA8940048OtherCRIME VICTIMS