Provider Demographics
NPI:1336134840
Name:PROSTKO, EDWARD RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:RICHARD
Last Name:PROSTKO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:E RICHARD
Other - Middle Name:
Other - Last Name:PROSTKO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:380 W CHESTNUT ST STE 101
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:15301-4658
Mailing Address - Country:US
Mailing Address - Phone:724-228-1414
Mailing Address - Fax:724-228-8579
Practice Address - Street 1:380 W CHESTNUT ST STE 101
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:PA
Practice Address - Zip Code:15301-4658
Practice Address - Country:US
Practice Address - Phone:724-228-1414
Practice Address - Fax:724-228-8579
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD024694E207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
10934442OtherCAQH
PA000888021Medicaid
070329Medicare PIN
WV0489005000Medicaid
PA0008880210008Medicaid
PAE79565Medicare UPIN
WV0489005000Medicaid
PA0888021Medicaid