Healthcare Provider Details

I. General information

NPI: 1831152198
Provider Name (Legal Business Name): PERRY D MOSTOV DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2006
Last Update Date: 06/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1344 WINTERGREEN LN NE
BAINBRIDGE ISLAND WA
98110
US

IV. Provider business mailing address

1344 WINTERGREEN LN NE
BAINBRIDGE ISLAND WA
98110-5118
US

V. Phone/Fax

Practice location:
  • Phone: 206-842-5632
  • Fax: 206-842-5992
Mailing address:
  • Phone: 206-842-5632
  • Fax: 206-842-5992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number34004921
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOP60744283
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: