Provider Demographics
NPI:1447276860
Name:DOSTALEK, GARY (OT)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:DOSTALEK
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 W AVENUE R12
Mailing Address - Street 2:
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93551-7700
Mailing Address - Country:US
Mailing Address - Phone:661-273-7515
Mailing Address - Fax:
Practice Address - Street 1:42283 10TH ST W
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-7073
Practice Address - Country:US
Practice Address - Phone:661-949-9655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5881225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
W0T5881AMedicare ID - Type Unspecified