Provider Demographics
NPI:1831189588
Name:RASTOGI, PRATIBHA (MD)
Entity type:Individual
Prefix:
First Name:PRATIBHA
Middle Name:
Last Name:RASTOGI
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:PO BOX 660832
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75266-0832
Mailing Address - Country:US
Mailing Address - Phone:972-715-5000
Mailing Address - Fax:
Practice Address - Street 1:13601 PRESTON RD
Practice Address - Street 2:SUITE 1000 W
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240-4911
Practice Address - Country:US
Practice Address - Phone:972-715-5007
Practice Address - Fax:972-715-5682
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036081961207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL27-4170061OtherBCBS
IL0360819616Medicaid
ILIL5259004Medicare PIN
F91361Medicare UPIN
IL0360819616Medicaid