Provider Demographics
NPI:1083615918
Name:CHWASTIAK, RICHARD (DPM)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:CHWASTIAK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:617 E BROAD ST
Mailing Address - Street 2:
Mailing Address - City:TAMAQUA
Mailing Address - State:PA
Mailing Address - Zip Code:18252-2206
Mailing Address - Country:US
Mailing Address - Phone:570-668-5170
Mailing Address - Fax:570-668-5171
Practice Address - Street 1:617 E BROAD ST
Practice Address - Street 2:
Practice Address - City:TAMAQUA
Practice Address - State:PA
Practice Address - Zip Code:18252-2206
Practice Address - Country:US
Practice Address - Phone:570-668-5170
Practice Address - Fax:570-668-5171
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-02
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC002158L213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA153345OtherHIGHMARK BLUE SHIELD
PA0787880001Medicare NSC
PA153345Medicare PIN
PA153345OtherHIGHMARK BLUE SHIELD