Provider Demographics
NPI:1881694909
Name:RASTGAR, KHOSROW (MD)
Entity type:Individual
Prefix:
First Name:KHOSROW
Middle Name:
Last Name:RASTGAR
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:PO BOX 95000-2705
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19195-2705
Mailing Address - Country:US
Mailing Address - Phone:609-441-2147
Mailing Address - Fax:609-441-2107
Practice Address - Street 1:1925 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:ATLANTIC CITY
Practice Address - State:NJ
Practice Address - Zip Code:08401-6713
Practice Address - Country:US
Practice Address - Phone:609-441-2147
Practice Address - Fax:609-441-2107
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03458300207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3816206Medicaid
NJE72683Medicare UPIN
220030379Medicare PIN
NJ652800CXLMedicare PIN