Provider Demographics
NPI:1205845096
Name:PHATAK, PRASHANT VASANT (MD)
Entity Type:Individual
Prefix:DR
First Name:PRASHANT
Middle Name:VASANT
Last Name:PHATAK
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:VA LOMA LINDA
Mailing Address - Street 2:11201 BENTON ST, DEPT 111H
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92357-0001
Mailing Address - Country:US
Mailing Address - Phone:909-825-7084
Mailing Address - Fax:
Practice Address - Street 1:VA LOMA LINDA
Practice Address - Street 2:11201 BENTON ST, DEPT 111H
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92357-0001
Practice Address - Country:US
Practice Address - Phone:909-825-7084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA74099207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine