Provider Demographics
NPI:1588642409
Name:ROSTAN, GARY (DO)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:
Last Name:ROSTAN
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 1:3811 E BELL RD
Mailing Address - Street 2:SUITE #111
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-2138
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3811 E BELL RD
Practice Address - Street 2:SUITE #111
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-2138
Practice Address - Country:US
Practice Address - Phone:602-923-4555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2948207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A93612Medicare UPIN