Provider Demographics
NPI:1306010970
Name:VIROSTKO, AMELIA ELISSA (MD)
Entity Type:Individual
Prefix:DR
First Name:AMELIA
Middle Name:ELISSA
Last Name:VIROSTKO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:203 S ROLLIE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LUPTON
Mailing Address - State:CO
Mailing Address - Zip Code:80621-1508
Mailing Address - Country:US
Mailing Address - Phone:303-286-4560
Mailing Address - Fax:303-286-4589
Practice Address - Street 1:1635 BLUE SPRUCE DR
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-5427
Practice Address - Country:US
Practice Address - Phone:970-494-4040
Practice Address - Fax:970-494-4076
Is Sole Proprietor?:No
Enumeration Date:2008-04-15
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0049964207Q00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO00579076Medicaid
COCOA108320Medicare PIN