Provider Demographics
NPI:1417928243
Name:PROSTKO, THOMAS RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:RICHARD
Last Name:PROSTKO
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 1:403 HILLCREST DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:EASLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29640-1207
Mailing Address - Country:US
Mailing Address - Phone:864-442-0771
Mailing Address - Fax:
Practice Address - Street 1:403 HILLCREST DR
Practice Address - Street 2:SUITE A
Practice Address - City:EASLEY
Practice Address - State:SC
Practice Address - Zip Code:29640-1207
Practice Address - Country:US
Practice Address - Phone:864-442-0771
Practice Address - Fax:864-442-0774
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-30
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13970207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3506Medicaid
SC7349Medicare PIN
SCB91507Medicare UPIN