Healthcare Provider Details

I. General information

NPI: 1265548945
Provider Name (Legal Business Name): RONALD V. WASHAK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 01/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 N ROCKTON AVE PLASTIC SURGERY DEPT
ROCKFORD IL
61103-3619
US

IV. Provider business mailing address

2300 N ROCKTON AVE PLASTIC SURGERY DEPT
ROCKFORD IL
61103-3619
US

V. Phone/Fax

Practice location:
  • Phone: 815-971-2000
  • Fax: 815-971-9924
Mailing address:
  • Phone: 815-971-2000
  • Fax: 815-971-9924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number036-128815
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number036-128815
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number036-128815
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code2082S0105X
TaxonomySurgery of the Hand (Plastic Surgery) Physician
License Number036128815
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: