Provider Demographics
NPI:1639647142
Name:GOSTOVICH, MICHAEL DEAN
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DEAN
Last Name:GOSTOVICH
Suffix:
Gender:M
Credentials:
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 354
Mailing Address - Street 2:
Mailing Address - City:BUENA
Mailing Address - State:WA
Mailing Address - Zip Code:98921-0354
Mailing Address - Country:US
Mailing Address - Phone:509-865-6705
Mailing Address - Fax:509-865-5011
Practice Address - Street 1:18 KENNY DR
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-2712
Practice Address - Country:US
Practice Address - Phone:509-952-2447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-02
Last Update Date:2018-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAGOSTOMD355N2OtherWADL