Provider Demographics
NPI:1245237411
Name:RUSTAGI, PREVESH K (MD)
Entity Type:Individual
Prefix:DR
First Name:PREVESH
Middle Name:K
Last Name:RUSTAGI
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 1:3400 E COLISEUM BLVD
Mailing Address - Street 2:SUITE 340
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-1644
Mailing Address - Country:US
Mailing Address - Phone:260-484-1312
Mailing Address - Fax:
Practice Address - Street 1:3400 E COLISEUM BLVD
Practice Address - Street 2:SUITE 340
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-1644
Practice Address - Country:US
Practice Address - Phone:260-484-1312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-03
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01035370A2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100081540AMedicaid
INE03949Medicare UPIN
IN100081540AMedicaid