Provider Demographics
NPI:1750329835
Name:LARGOSA, ANASTACIA R (MD)
Entity Type:Individual
Prefix:DR
First Name:ANASTACIA
Middle Name:R
Last Name:LARGOSA
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 1:10448 S PULASKI RD
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-4895
Mailing Address - Country:US
Mailing Address - Phone:708-424-7705
Mailing Address - Fax:708-424-0502
Practice Address - Street 1:10448 S PULASKI RD
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-4895
Practice Address - Country:US
Practice Address - Phone:708-424-7705
Practice Address - Fax:708-424-0502
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036057514207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036057514Medicaid
IL036057514Medicaid
IL616150Medicare ID - Type Unspecified