Provider Demographics
NPI:1083677413
Name:PRASTHOFER, EDGAR FRIEDRICH (MD)
Entity Type:Individual
Prefix:
First Name:EDGAR
Middle Name:FRIEDRICH
Last Name:PRASTHOFER
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 1:1333 CHANDLER DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84103-4216
Mailing Address - Country:US
Mailing Address - Phone:801-359-4205
Mailing Address - Fax:
Practice Address - Street 1:1 MERCADO ST
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-7306
Practice Address - Country:US
Practice Address - Phone:970-385-7977
Practice Address - Fax:970-385-6727
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO42668174400000X
OH35132100207RH0000X, 207RX0202X
UT9511470-1205207RH0003X, 207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No174400000XOther Service ProvidersSpecialist
No207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0237183Medicaid
COCO40159Medicare PIN
COC73921Medicare UPIN