Provider Demographics
NPI:1528594124
Name:VASHISTA, PRATIBHA SONAM (DO)
Entity Type:Individual
Prefix:
First Name:PRATIBHA
Middle Name:SONAM
Last Name:VASHISTA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 QUINTARD AVE
Mailing Address - Street 2:
Mailing Address - City:ANNISTON
Mailing Address - State:AL
Mailing Address - Zip Code:36201-4619
Mailing Address - Country:US
Mailing Address - Phone:256-741-1339
Mailing Address - Fax:
Practice Address - Street 1:1325 QUINTARD AVE
Practice Address - Street 2:
Practice Address - City:ANNISTON
Practice Address - State:AL
Practice Address - Zip Code:36201-4619
Practice Address - Country:US
Practice Address - Phone:256-741-1339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-03
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC390200000X
ALDO.2317207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program