Provider Demographics
NPI:1427042381
Name:ROSTOVTSEVA, SOPHIA (MD)
Entity Type:Individual
Prefix:
First Name:SOPHIA
Middle Name:
Last Name:ROSTOVTSEVA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6810 STATE ROUTE 162 BOX 215
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-8501
Mailing Address - Country:US
Mailing Address - Phone:618-391-6405
Mailing Address - Fax:618-258-4088
Practice Address - Street 1:6812 STATE ROUTE 162
Practice Address - Street 2:STE 120
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-8553
Practice Address - Country:US
Practice Address - Phone:618-288-0044
Practice Address - Fax:618-288-0066
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036107786207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036107786Medicaid
ILP00390708OtherRR MEDICARE
ILK14670Medicare ID - Type Unspecified
ILP00390708OtherRR MEDICARE
IL036107786Medicaid