Provider Demographics
NPI:1225062292
Name:PRABHAKAR, KUSUM R (MD)
Entity Type:Individual
Prefix:DR
First Name:KUSUM
Middle Name:R
Last Name:PRABHAKAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1336 WYOMING BLVD NE
Mailing Address - Street 2:SUITE F
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-5066
Mailing Address - Country:US
Mailing Address - Phone:505-275-2442
Mailing Address - Fax:505-275-2443
Practice Address - Street 1:1336 WYOMING BLVD NE
Practice Address - Street 2:SUITE F
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-5066
Practice Address - Country:US
Practice Address - Phone:505-275-2442
Practice Address - Fax:505-275-2443
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NM77-234207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NME09272Medicare UPIN
NM2120801Medicare ID - Type Unspecified