1912965484 NPI number — DR. RICHARD OSTROM PHD

Table of content: DR. RICHARD OSTROM PHD (NPI 1912965484)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912965484 NPI number — DR. RICHARD OSTROM PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OSTROM
Provider First Name:
RICHARD
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD
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:
1912965484
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9340 NE 76TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VANCOUVER
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98662-3721
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-253-4912
Provider Business Mailing Address Fax Number:
360-253-5170

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1500 3RD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONGVIEW
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98632-3229
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-423-8800
Provider Business Practice Location Address Fax Number:
360-636-3421
Provider Enumeration Date:
05/03/2006

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: 103TC0700X , with the licence number:  PY00002822 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8357964 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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