Provider Demographics
NPI:1457328023
Name:SASTRY, PILLUTLA VENKATA (MD)
Entity Type:Individual
Prefix:DR
First Name:PILLUTLA
Middle Name:VENKATA
Last Name:SASTRY
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 1:100 BENTLEY AVE
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07304-1702
Mailing Address - Country:US
Mailing Address - Phone:201-433-5678
Mailing Address - Fax:201-433-6502
Practice Address - Street 1:100 BENTLEY AVE
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07304-1702
Practice Address - Country:US
Practice Address - Phone:201-433-5678
Practice Address - Fax:201-433-6502
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-02
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ029198174400000X
NJ25MA02919800207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJC53103Medicare UPIN
NJ086680Medicare ID - Type Unspecified