Provider Demographics
NPI:1235105826
Name:PRASAD, MIRAMAR S (MD)
Entity Type:Individual
Prefix:DR
First Name:MIRAMAR
Middle Name:S
Last Name:PRASAD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5401 44TH AVENUE DRIVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:51265-6401
Mailing Address - Country:US
Mailing Address - Phone:309-779-5439
Mailing Address - Fax:309-558-7026
Practice Address - Street 1:5401 44TH AVENUE DRIVE
Practice Address - Street 2:SUITE 100
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:51265-6401
Practice Address - Country:US
Practice Address - Phone:309-779-5439
Practice Address - Fax:309-558-7026
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036084335207Q00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2924712Medicaid
IL1235105826Medicaid
IL1235105826Medicaid
L81702Medicare ID - Type UnspecifiedINDIVIDUAL
IA2924712Medicaid
IA1924712Medicare ID - Type UnspecifiedIA MEDICAID E MOLINE
IL200715022Medicare PIN