Healthcare Provider Details

I. General information

NPI: 1902063282
Provider Name (Legal Business Name): JACK W ROSTAS III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2008
Last Update Date: 08/17/2023
Certification Date: 08/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4101 22ND PL
LUBBOCK TX
79410-1121
US

IV. Provider business mailing address

3509 22ND ST
LUBBOCK TX
79410-1307
US

V. Phone/Fax

Practice location:
  • Phone: 806-799-7928
  • Fax: 806-788-8560
Mailing address:
  • Phone: 806-799-7928
  • Fax: 806-788-8560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number036143962
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License NumberT5200
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: