Provider Demographics
NPI:1235124991
Name:RASTOGI, SHANTANU (MD)
Entity Type:Individual
Prefix:
First Name:SHANTANU
Middle Name:
Last Name:RASTOGI
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 1:977 48TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11219-2919
Mailing Address - Country:US
Mailing Address - Phone:718-283-8015
Mailing Address - Fax:718-635-7235
Practice Address - Street 1:4802 10TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-2844
Practice Address - Country:US
Practice Address - Phone:718-283-8853
Practice Address - Fax:718-635-7235
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0009692080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2050698OtherUNITED HEALTHCARE
NY2603108OtherGHI
NY02128949Medicaid
NY000969OtherHIP
NYP2171926OtherOXFORD HEALTH PLAN
NYRS0969OtherATLANTIS HEALTH
NY1000029918OtherAFFINITY HEALTH
NY000969-A15OtherHEALTH FIRST
NY4C4443OtherHEALTH NET
NY1Q9251Medicare ID - Type Unspecified
NYH30033Medicare UPIN