1639647142 NPI number — MICHAEL DEAN GOSTOVICH

Table of content: MICHAEL DEAN GOSTOVICH (NPI 1639647142)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639647142 NPI number — MICHAEL DEAN GOSTOVICH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOSTOVICH
Provider First Name:
MICHAEL
Provider Middle Name:
DEAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639647142
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/02/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 354
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BUENA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98921-0354
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-865-6705
Provider Business Mailing Address Fax Number:
509-865-5011

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18 KENNY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
YAKIMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98902-2712
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-952-2447
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/02/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171WH0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: GOSTOMD355N2 . This is a "WADL" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com