Provider Demographics
NPI:1477549913
Name:LOSTAK, CHARLES JOHN (DO)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:JOHN
Last Name:LOSTAK
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 1:3450 W WHEATLAND RD
Mailing Address - Street 2:POB II, SUITE 245
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75237-3470
Mailing Address - Country:US
Mailing Address - Phone:214-948-8856
Mailing Address - Fax:214-948-5516
Practice Address - Street 1:3450 W WHEATLAND RD
Practice Address - Street 2:POB II, SUITE 245
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75237-3470
Practice Address - Country:US
Practice Address - Phone:214-948-8856
Practice Address - Fax:214-948-5516
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH0576207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX172179701Medicaid
TXA67347Medicare UPIN
TX172179701Medicaid