Healthcare Provider Details

I. General information

NPI: 1669693743
Provider Name (Legal Business Name): JOSEPH S RASTROLLO MD A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 07/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1805 MEDICAL CENTER DR
SAN BERNARDINO CA
92411-1217
US

IV. Provider business mailing address

210 N TUSTIN AVE
SANTA ANA CA
92705-3807
US

V. Phone/Fax

Practice location:
  • Phone: 909-887-6333
  • Fax:
Mailing address:
  • Phone: 800-883-7243
  • Fax: 714-647-1245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA33366
License Number StateCA

VIII. Authorized Official

Name: JOSEPH RASTROLLO
Title or Position: PRESIDENT
Credential: MD
Phone: 909-799-9115