Provider Demographics
NPI:1104026236
Name:NAIR, PREM KRISHNAN KUTTY (MD)
Entity Type:Individual
Prefix:
First Name:PREM
Middle Name:KRISHNAN KUTTY
Last Name:NAIR
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 1:701 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79763-4206
Mailing Address - Country:US
Mailing Address - Phone:432-403-5340
Mailing Address - Fax:432-353-5262
Practice Address - Street 1:2901 S LYNNHAVEN RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-8505
Practice Address - Country:US
Practice Address - Phone:432-703-5507
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-18
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35096635207R00000X
TXR6250207R00000X
MDD77710208M00000X
NC2007-01140208M00000X
VA0101245671207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5907718Medicaid
NC2069641Medicare PIN