Provider Demographics
NPI:1265522239
Name:ROSTAN, ELIZABETH FAIRCLOTH (MD)
Entity type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:FAIRCLOTH
Last Name:ROSTAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:130 PROVIDENCE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28207-1242
Mailing Address - Country:US
Mailing Address - Phone:704-333-9113
Mailing Address - Fax:704-333-9757
Practice Address - Street 1:130 PROVIDENCE RD STE 100
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1242
Practice Address - Country:US
Practice Address - Phone:704-333-9113
Practice Address - Fax:704-333-9757
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC9700237207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2285407Medicare ID - Type Unspecified
NCH08009Medicare UPIN