Provider Demographics
NPI:1003130204
Name:MY FAMILY DOCTOR IN THE VALLEY PLLC
Entity Type:Organization
Organization Name:MY FAMILY DOCTOR IN THE VALLEY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:NIREK
Authorized Official - Middle Name:
Authorized Official - Last Name:RASTOGI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-687-8265
Mailing Address - Street 1:PO BOX 31853
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85046-1853
Mailing Address - Country:US
Mailing Address - Phone:602-687-8265
Mailing Address - Fax:
Practice Address - Street 1:11030 N TATUM BLVD
Practice Address - Street 2:STE 101
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-6073
Practice Address - Country:US
Practice Address - Phone:602-687-8265
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-17
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ36997207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty