Basic Information
| Provider Information | |||||||||
| NPI: | 1871551184 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KASTURI, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1730 PARK ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | NAPERVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605632688 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6307180200 | ||||||||
| FaxNumber: | 6307180900 | ||||||||
| Practice Location | |||||||||
| Address1: | 1111 SUPERIOR ST | ||||||||
| Address2: | SUITE 507 | ||||||||
| City: | MELROSE PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601604138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7086814040 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 02/12/2010 | ||||||||
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| AuthorizedOfficialLastName: | KASTURI | ||||||||
| AuthorizedOfficialFirstName: | JAYA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 6307180200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 31602382 | 01 | IL | BLUE CROSS / BLUE SHIELD | OTHER |