Provider Demographics
NPI:1083795850
Name:SHIVAPRASAD, MABBU GAJAPATHY (MD)
Entity Type:Individual
Prefix:
First Name:MABBU
Middle Name:GAJAPATHY
Last Name:SHIVAPRASAD
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 1:2210 TIMBER TRAIL
Mailing Address - Street 2:
Mailing Address - City:BELLEFONTAINE
Mailing Address - State:OH
Mailing Address - Zip Code:43311
Mailing Address - Country:US
Mailing Address - Phone:937-593-3151
Mailing Address - Fax:937-593-5438
Practice Address - Street 1:LOGAN FAMILY MEDICAL CENTER LLC
Practice Address - Street 2:2210 TIMBER TRAIL
Practice Address - City:BELLEFONTAINE
Practice Address - State:OH
Practice Address - Zip Code:43311
Practice Address - Country:US
Practice Address - Phone:937-593-3151
Practice Address - Fax:937-593-5438
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-072257207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2017373Medicaid
OHSH0828933Medicare ID - Type Unspecified
G56416Medicare UPIN