Provider Demographics
NPI:1033271010
Name:THYAGARAJAN, PRABAKAR (MD)
Entity Type:Individual
Prefix:DR
First Name:PRABAKAR
Middle Name:
Last Name:THYAGARAJAN
Suffix:
Gender:M
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 GRANITE STREET,
Mailing Address - Street 2:BAYRIDGE HOSPITAL,
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01904
Mailing Address - Country:US
Mailing Address - Phone:781-477-6930
Mailing Address - Fax:
Practice Address - Street 1:60 GRANITE STREET,
Practice Address - Street 2:BAYRIDGE HOSPITAL,
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01904
Practice Address - Country:US
Practice Address - Phone:781-477-6930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1524602084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3163326Medicaid