Provider Demographics
NPI:1649253840
Name:FROSTAD, MICHAEL J (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:FROSTAD
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 1:1205 SE PROFESSIONAL MALL BLVD
Mailing Address - Street 2:SUITE104
Mailing Address - City:PULLMAN
Mailing Address - State:WA
Mailing Address - Zip Code:99163-5423
Mailing Address - Country:US
Mailing Address - Phone:509-332-2605
Mailing Address - Fax:509-334-5754
Practice Address - Street 1:1205 SE PROFESSIONAL MALL BLVD
Practice Address - Street 2:SUITE104
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99163-5423
Practice Address - Country:US
Practice Address - Phone:509-332-2605
Practice Address - Fax:509-334-5754
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00039818208000000X
IDM-8243208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8275828Medicaid
H48514Medicare UPIN
WAAB28381Medicare ID - Type Unspecified