Provider Demographics
NPI:1164479606
Name:PRABHU, PANDURANG M (MD)
Entity Type:Individual
Prefix:
First Name:PANDURANG
Middle Name:M
Last Name:PRABHU
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 1:3131 NYS ROUTE 9W
Mailing Address - Street 2:
Mailing Address - City:NEW WINDSOR
Mailing Address - State:NY
Mailing Address - Zip Code:12553-6755
Mailing Address - Country:US
Mailing Address - Phone:845-561-2040
Mailing Address - Fax:
Practice Address - Street 1:3131 NYS ROUTE 9W
Practice Address - Street 2:
Practice Address - City:NEW WINDSOR
Practice Address - State:NY
Practice Address - Zip Code:12553-6755
Practice Address - Country:US
Practice Address - Phone:845-561-2040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-30
Last Update Date:2008-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY145840207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY006671ME07Medicaid
NYWGW981Medicare PIN
D47471Medicare UPIN
52A471Medicare ID - Type Unspecified