Provider Demographics
NPI:1033104674
Name:PRAKASH, RENU B (MD)
Entity Type:Individual
Prefix:
First Name:RENU
Middle Name:B
Last Name:PRAKASH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 GRAND STREET
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MA
Mailing Address - Zip Code:02021-1836
Mailing Address - Country:US
Mailing Address - Phone:781-821-0194
Mailing Address - Fax:781-821-0194
Practice Address - Street 1:60 GRAND ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MA
Practice Address - Zip Code:02021-1836
Practice Address - Country:US
Practice Address - Phone:781-821-0194
Practice Address - Fax:781-821-0194
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA159456207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAS400105529OtherMEDICARE - GROUP #003473101
MAS400105532OtherMEDICARE - GROUP #0034731
MA3190935Medicaid
MAS400105532OtherMEDICARE - GROUP #0034731