Healthcare Provider Details

I. General information

NPI: 1235124991
Provider Name (Legal Business Name): SHANTANU RASTOGI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4802 10TH AVE
BROOKLYN NY
11219-2844
US

IV. Provider business mailing address

977 48TH ST
BROOKLYN NY
11219-2919
US

V. Phone/Fax

Practice location:
  • Phone: 718-283-8853
  • Fax: 718-635-7235
Mailing address:
  • Phone: 718-283-8015
  • Fax: 718-635-7235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number000969
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: