1700958873 NPI number — PRASAD S VANKINENI MD

Table of content: PRASAD S VANKINENI MD (NPI 1700958873)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700958873 NPI number — PRASAD S VANKINENI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VANKINENI
Provider First Name:
PRASAD
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:
1700958873
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/27/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
420 LOWELL DRIVE
Provider Second Line Business Mailing Address:
SUITE 204
Provider Business Mailing Address City Name:
HUNTSVILLE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35801-3763
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-536-9031
Provider Business Mailing Address Fax Number:
256-539-4240

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
420 LOWELL DR.
Provider Second Line Business Practice Location Address:
SUITE 204
Provider Business Practice Location Address City Name:
HUNTSVILLE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35801-3763
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-536-9031
Provider Business Practice Location Address Fax Number:
256-539-4240
Provider Enumeration Date:
11/14/2006

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: 207RG0100X , with the licence number:  10838 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000011586 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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