Provider Demographics
NPI:1033315932
Name:PRAKASH, BALA (MD)
Entity Type:Individual
Prefix:DR
First Name:BALA
Middle Name:
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 1:744 S WEBSTER AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-3505
Mailing Address - Country:US
Mailing Address - Phone:920-445-7226
Mailing Address - Fax:920-445-7229
Practice Address - Street 1:PH USC PULMONARY
Practice Address - Street 2:300 PALMETTO HEALTH PARKWAY
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29212-1765
Practice Address - Country:US
Practice Address - Phone:803-296-3273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-26
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY260043-1207R00000X, 207RC0200X, 207RP1001X
WI64322-20207R00000X
KY48315207RC0200X, 207RP1001X
SC38574207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC385746Medicaid