Provider Demographics
NPI:1942301437
Name:RASTAWAN, SIYAMAC (DPT)
Entity Type:Individual
Prefix:DR
First Name:SIYAMAC
Middle Name:
Last Name:RASTAWAN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1751 W ROMNEYA DR
Mailing Address - Street 2:SUITE M
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92801-1817
Mailing Address - Country:US
Mailing Address - Phone:714-774-6000
Mailing Address - Fax:714-774-6100
Practice Address - Street 1:1751 W ROMNEYA DR
Practice Address - Street 2:SUITE M
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-1817
Practice Address - Country:US
Practice Address - Phone:714-774-6000
Practice Address - Fax:714-774-6100
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2009-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25213225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW19052Medicare ID - Type UnspecifiedGROUP ID