Provider Demographics
NPI:1194211672
Name:PRAKASH, AMULYA (MD)
Entity Type:Individual
Prefix:DR
First Name:AMULYA
Middle Name:
Last Name:PRAKASH
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 1:73 CEDAR AVENUE
Mailing Address - Street 2:APT 56, GLEN ELLEN HOMES
Mailing Address - City:LONG BRANCH
Mailing Address - State:NJ
Mailing Address - Zip Code:07740
Mailing Address - Country:US
Mailing Address - Phone:732-610-3893
Mailing Address - Fax:
Practice Address - Street 1:300 2ND AVE
Practice Address - Street 2:
Practice Address - City:LONG BRANCH
Practice Address - State:NJ
Practice Address - Zip Code:07740-6395
Practice Address - Country:US
Practice Address - Phone:732-610-3893
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-08
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC2021-01863207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program