Provider Demographics
NPI:1073122123
Name:UPADRISTA, PRATAP KUMAR
Entity Type:Individual
Prefix:MR
First Name:PRATAP KUMAR
Middle Name:
Last Name:UPADRISTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10, BURNS AVENUE,
Mailing Address - Street 2:
Mailing Address - City:HICKSVILLE, NASSAU
Mailing Address - State:NY
Mailing Address - Zip Code:11801
Mailing Address - Country:US
Mailing Address - Phone:614-816-7497
Mailing Address - Fax:
Practice Address - Street 1:2201 HEMPSTEAD TURNPIKE
Practice Address - Street 2:
Practice Address - City:EAST MEADOW
Practice Address - State:NY
Practice Address - Zip Code:11554
Practice Address - Country:US
Practice Address - Phone:614-816-7497
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-24
Last Update Date:2021-12-06
Deactivation Date:2021-10-20
Deactivation Code:
Reactivation Date:2021-12-06
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program