Basic Information
| Provider Information | |||||||||
| NPI: | 1538164868 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VIROSTKO | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 409 S 4TH ST | ||||||||
| Address2: | |||||||||
| City: | COSHOCTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 438122024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7406220332 | ||||||||
| FaxNumber: | 7406220335 | ||||||||
| Practice Location | |||||||||
| Address1: | 440 BROWNS LN | ||||||||
| Address2: | |||||||||
| City: | COSHOCTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 438122044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7406220332 | ||||||||
| FaxNumber: | 7406220335 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2005 | ||||||||
| LastUpdateDate: | 08/08/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35062459 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0861447 | 05 | OH | MEDICAID |