Provider Demographics
NPI:1144293226
Name:ROISTACHER, RICHARD MICHAEL (MD)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:MICHAEL
Last Name:ROISTACHER
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 1:8397 W OAKLAND PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33351-7307
Mailing Address - Country:US
Mailing Address - Phone:954-741-5000
Mailing Address - Fax:954-741-1177
Practice Address - Street 1:8397 W OAKLAND PARK BLVD
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33351-7307
Practice Address - Country:US
Practice Address - Phone:954-741-5000
Practice Address - Fax:954-741-1177
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0040204207QA0505X
OH35049692R207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D58912Medicare UPIN
FL79758Medicare ID - Type Unspecified