Provider Demographics
NPI:1538121769
Name:ROSTYKUS, PAUL (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:ROSTYKUS
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:PO BOX 34935
Mailing Address - Street 2:DEPARTMENT 563
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1935
Mailing Address - Country:US
Mailing Address - Phone:888-633-0079
Mailing Address - Fax:
Practice Address - Street 1:280 MAPLE ST
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520-1552
Practice Address - Country:US
Practice Address - Phone:541-201-4100
Practice Address - Fax:541-488-7434
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2011-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD15433207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
97520A006OtherCHAMPUS
B42699OtherGROUP HEALTH
023507000OtherBC/BS OF OREGON
OR170084Medicaid
930079052OtherRAILROAD MEDICARE
B42699OtherPROVIDENCE HEALTH PLAN
XPY185097OtherMEDI CAL
B42699OtherGROUP HEALTH
OR170084Medicaid