Provider Demographics
NPI:1467448977
Name:PASTIKA, BENNETT JOHN (DO)
Entity Type:Individual
Prefix:
First Name:BENNETT
Middle Name:JOHN
Last Name:PASTIKA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:414-389-2131
Mailing Address - Fax:
Practice Address - Street 1:855 N WESTHAVEN DR
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54904-7668
Practice Address - Country:US
Practice Address - Phone:920-303-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036077460207RG0100X
WI35507207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30062100Medicaid
524450002Medicare ID - Type Unspecified
F79719Medicare UPIN