Provider Demographics
NPI:1720074875
Name:ERBSTOESZER, JOHN W (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:W
Last Name:ERBSTOESZER
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 1:1400 E KINCAID ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-4127
Mailing Address - Country:US
Mailing Address - Phone:360-428-2500
Mailing Address - Fax:360-428-6485
Practice Address - Street 1:1400 E KINCAID ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98274-4127
Practice Address - Country:US
Practice Address - Phone:360-428-2500
Practice Address - Fax:360-428-6485
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00012574207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1244300Medicaid
WA1244300Medicaid
A08984Medicare UPIN