Provider Demographics
NPI:1164829131
Name:PRAKASH, NISHA (OD)
Entity Type:Individual
Prefix:DR
First Name:NISHA
Middle Name:
Last Name:PRAKASH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5323 MOUNT VIEW RD
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:TN
Mailing Address - Zip Code:37013-2308
Mailing Address - Country:US
Mailing Address - Phone:615-731-8900
Mailing Address - Fax:
Practice Address - Street 1:1384 TOWNE SQUARE BLVD NW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24012-1611
Practice Address - Country:US
Practice Address - Phone:540-278-2880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-19
Last Update Date:2016-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNODT3271152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist