Provider Demographics
NPI:1053649566
Name:PRADA, STEPHANIE (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:PRADA
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 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-434-9358
Mailing Address - Fax:321-951-7408
Practice Address - Street 1:8745 N WICKHAM RD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-5997
Practice Address - Country:US
Practice Address - Phone:321-434-9358
Practice Address - Fax:321-434-9170
Is Sole Proprietor?:No
Enumeration Date:2009-11-20
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME113082208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL005946900Medicaid
FLGI464XOtherMEDICARE