Provider Demographics
NPI:1265548945
Name:WASHAK, RONALD V (DO)
Entity type:Individual
Prefix:DR
First Name:RONALD
Middle Name:V
Last Name:WASHAK
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:2300 N ROCKTON AVE
Mailing Address - Street 2:PLASTIC SURGERY DEPT
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61103-3619
Mailing Address - Country:US
Mailing Address - Phone:815-971-2000
Mailing Address - Fax:815-971-9924
Practice Address - Street 1:2300 N ROCKTON AVE
Practice Address - Street 2:PLASTIC SURGERY DEPT
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61103-3619
Practice Address - Country:US
Practice Address - Phone:815-971-2000
Practice Address - Fax:815-971-9924
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2015-01-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL036-128815207Y00000X, 207YS0123X, 2086S0122X, 2086S0122X
IL0361288152082S0105X
WI293150212082S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
No2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1265548945Medicaid
WI1265548945Medicaid
WI543300101Medicare PIN