Healthcare Provider Details

I. General information

NPI: 1255785838
Provider Name (Legal Business Name): VAIBHAV RASTOGI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2016
Last Update Date: 10/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 NW 16TH AVE
GAINESVILLE FL
32601-4012
US

IV. Provider business mailing address

6500 W NEWBERRY RD
GAINESVILLE FL
32605-4309
US

V. Phone/Fax

Practice location:
  • Phone: 352-333-5700
  • Fax: 352-333-3157
Mailing address:
  • Phone: 352-333-5159
  • Fax: 352-333-3157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberTRN22617
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: