Provider Demographics
NPI:1962603472
Name:ANASTACIA R. LARGOSA MD
Entity type:Organization
Organization Name:ANASTACIA R. LARGOSA MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANASTACIA
Authorized Official - Middle Name:R
Authorized Official - Last Name:LARGOSA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-424-7705
Mailing Address - Street 1:10448 S PULASKI RD
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-4895
Mailing Address - Country:US
Mailing Address - Phone:708-424-7705
Mailing Address - Fax:708-424-0502
Practice Address - Street 1:10448 S PULASKI RD
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-4895
Practice Address - Country:US
Practice Address - Phone:708-424-7705
Practice Address - Fax:708-424-0502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-30
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036057514207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036057514Medicaid
IL616150Medicare ID - Type Unspecified
IL036057514Medicaid