1700800661 NPI number — RAGHAVENDRA S PRASAD MD

Table of content: RAGHAVENDRA S PRASAD MD (NPI 1700800661)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700800661 NPI number — RAGHAVENDRA S PRASAD MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PRASAD
Provider First Name:
RAGHAVENDRA
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700800661
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/19/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
445 E FM 1382 #3354
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CEDAR HILL
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75104
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-325-1969
Provider Business Mailing Address Fax Number:
972-291-0019

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
445 E FM 1382 #3354
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CEDAR HILL
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-325-1969
Provider Business Practice Location Address Fax Number:
972-291-0019
Provider Enumeration Date:
07/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207QG0300X , with the licence number:  J6213 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 148776103 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8F7027 . This is a "INDIVIDUAL PTAN #/ ELLIS & COLLINS COUNTY" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8F7028 . This is a "INDIVIDUAL PTAN #/ TARRANT COUNTY" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 132640710 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8F7018 . This is a "INDIVIDUAL PTAN/ DALLAS COUNTY" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 148776102 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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