Provider Demographics
NPI:1134110158
Name:PRASAD, MANJU L (MD)
Entity Type:Individual
Prefix:
First Name:MANJU
Middle Name:L
Last Name:PRASAD
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 1:20 YORK ST
Mailing Address - Street 2:EP#2-608B
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-3220
Mailing Address - Country:US
Mailing Address - Phone:203-737-4862
Mailing Address - Fax:203-737-2922
Practice Address - Street 1:20 YORK ST
Practice Address - Street 2:EP#2-608B
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3220
Practice Address - Country:US
Practice Address - Phone:203-737-4862
Practice Address - Fax:203-737-2922
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2009-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT043615207ZP0101X
MA220310207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2067030Medicaid
MARX2360Medicare PIN
MAH20468Medicare UPIN