1174508469 NPI number — DR. PRAYOON PRABHARASUTH MD

Table of content: DR. PRAYOON PRABHARASUTH MD (NPI 1174508469)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174508469 NPI number — DR. PRAYOON PRABHARASUTH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PRABHARASUTH
Provider First Name:
PRAYOON
Provider Middle Name:
Provider Name Prefix Text:
DR.
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:
1174508469
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/18/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2594 WILLIAM ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWFANE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14108-1026
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-778-7118
Provider Business Mailing Address Fax Number:
716-778-7119

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2594 WILLIAM ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWFANE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14108-1026
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-778-7118
Provider Business Practice Location Address Fax Number:
716-778-7119
Provider Enumeration Date:
12/09/2005

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: 207V00000X , with the licence number:  115344 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0028508 . This is a "GHI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 10200140 . This is a "FIDELIS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 00615027 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 80121005055741 . This is a "BSBC GENERAL MOTORS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0004301613 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000505574001 . This is a "BCBS OF WNY" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00020503901 . This is a "UNIVERA HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0701266 . This is a "INDEPENDENT HEALTH ASSOCI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 161068845001 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".




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