Provider Demographics
NPI:1891741344
Name:RASTOGI, SURENDER M (MD)
Entity Type:Individual
Prefix:DR
First Name:SURENDER
Middle Name:M
Last Name:RASTOGI
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 1:8306 KENNEDY BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH BERGEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07047-4264
Mailing Address - Country:US
Mailing Address - Phone:201-868-1333
Mailing Address - Fax:201-868-3235
Practice Address - Street 1:8306 KENNEDY BLVD
Practice Address - Street 2:
Practice Address - City:NORTH BERGEN
Practice Address - State:NJ
Practice Address - Zip Code:07047-4264
Practice Address - Country:US
Practice Address - Phone:201-868-1333
Practice Address - Fax:201-868-3235
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-26
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04031600207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1841009-01Medicaid
NJMA40316OtherLICENSE NUMBER
NJMA40316OtherLICENSE NUMBER
C55625Medicare UPIN