Provider Demographics
NPI:1164520870
Name:VIVEK, PRASHANT P (MD)
Entity Type:Individual
Prefix:
First Name:PRASHANT
Middle Name:P
Last Name:VIVEK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1648
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97440-1648
Mailing Address - Country:US
Mailing Address - Phone:541-334-3370
Mailing Address - Fax:541-334-3372
Practice Address - Street 1:330 S GARDEN WAY
Practice Address - Street 2:SUITE 300
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-8176
Practice Address - Country:US
Practice Address - Phone:541-334-3370
Practice Address - Fax:541-334-3372
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ORMD27513207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR006392Medicaid
R158131Medicare PIN