Provider Demographics
NPI:1417123977
Name:JASTI, PALLAVI (MD)
Entity Type:Individual
Prefix:DR
First Name:PALLAVI
Middle Name:
Last Name:JASTI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4646 JOHN R ST
Mailing Address - Street 2:11-HMO
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-1916
Mailing Address - Country:US
Mailing Address - Phone:313-576-1000
Mailing Address - Fax:313-576-1824
Practice Address - Street 1:15855 19 MILE RD
Practice Address - Street 2:
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48038-3504
Practice Address - Country:US
Practice Address - Phone:586-263-2506
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-05
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301082244207RH0003X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301082244OtherSTATE LICENSE
MI5315027169OtherCONTROLLED DRUG LICENSE
MI0930080OtherBCBSM
MI4301082244OtherSTATE LICENSE
MI5315027169OtherCONTROLLED DRUG LICENSE