Provider Demographics
NPI:1427057512
Name:ROSTOV, AUDREY R (MD)
Entity type:Individual
Prefix:DR
First Name:AUDREY
Middle Name:R
Last Name:ROSTOV
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1231 116TH AVE NE STE 450
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-3837
Mailing Address - Country:US
Mailing Address - Phone:425-866-2020
Mailing Address - Fax:
Practice Address - Street 1:1231 116TH AVE NE STE 450
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-3804
Practice Address - Country:US
Practice Address - Phone:425-866-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2025-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00030598207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8155244Medicaid
WA001148893Medicare ID - Type UnspecifiedSMOKEY POINT CLINIC
WA115103305Medicare ID - Type UnspecifiedSEQUIM CLINIC
WA8155244Medicaid