Provider Demographics
NPI:1003846635
Name:PRAKASH, JAY R (MD)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:R
Last Name:PRAKASH
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:6555 PROFESSIONAL PL
Mailing Address - Street 2:SUITE C
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-2519
Mailing Address - Country:US
Mailing Address - Phone:770-996-5959
Mailing Address - Fax:770-991-1596
Practice Address - Street 1:6555 PROFESSIONAL PL
Practice Address - Street 2:SUITE C
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-2519
Practice Address - Country:US
Practice Address - Phone:770-996-5959
Practice Address - Fax:770-991-1596
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA025986207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00292322AMedicaid
GAD40253Medicare UPIN