Provider Demographics
NPI:1174508469
Name:PRABHARASUTH, PRAYOON (MD)
Entity Type:Individual
Prefix:DR
First Name:PRAYOON
Middle Name:
Last Name:PRABHARASUTH
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 1:2594 WILLIAM ST
Mailing Address - Street 2:
Mailing Address - City:NEWFANE
Mailing Address - State:NY
Mailing Address - Zip Code:14108-1026
Mailing Address - Country:US
Mailing Address - Phone:716-778-7118
Mailing Address - Fax:716-778-7119
Practice Address - Street 1:2594 WILLIAM ST
Practice Address - Street 2:
Practice Address - City:NEWFANE
Practice Address - State:NY
Practice Address - Zip Code:14108-1026
Practice Address - Country:US
Practice Address - Phone:716-778-7118
Practice Address - Fax:716-778-7119
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2010-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY115344207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
0028508OtherGHI
10200140OtherFIDELIS
NY00615027Medicaid
80121005055741OtherBSBC GENERAL MOTORS
0004301613OtherAETNA
NY000505574001OtherBCBS OF WNY
00020503901OtherUNIVERA HEALTHCARE
0701266OtherINDEPENDENT HEALTH ASSOCI
161068845001OtherTRICARE
055741Medicare ID - Type Unspecified
10200140OtherFIDELIS