Provider Demographics
NPI:1275641425
Name:WOLOSCHUK, OSTAP (MD)
Entity Type:Individual
Prefix:
First Name:OSTAP
Middle Name:
Last Name:WOLOSCHUK
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:PO BOX 1211
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35653-1211
Mailing Address - Country:US
Mailing Address - Phone:256-332-7233
Mailing Address - Fax:256-332-7238
Practice Address - Street 1:604 GANDY ST NE
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AL
Practice Address - Zip Code:35653-1912
Practice Address - Country:US
Practice Address - Phone:256-332-7233
Practice Address - Fax:256-332-7238
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL11365173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALC71133Medicare UPIN