Provider Demographics
NPI:1164506770
Name:PRASAD, JUSTIN (OD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:
Last Name:PRASAD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6332 E SPRING ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90815-1424
Mailing Address - Country:US
Mailing Address - Phone:562-421-4488
Mailing Address - Fax:562-421-0233
Practice Address - Street 1:6332 E SPRING ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90815-1424
Practice Address - Country:US
Practice Address - Phone:562-421-4488
Practice Address - Fax:562-421-0233
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT12697T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0126970Medicaid