Provider Demographics
NPI:1265508238
Name:PRABHU, MALLAPPA NANJAPPA (MD)
Entity Type:Individual
Prefix:
First Name:MALLAPPA
Middle Name:NANJAPPA
Last Name:PRABHU
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 1:2 HILARY TER
Mailing Address - Street 2:
Mailing Address - City:SUCCASUNNA
Mailing Address - State:NJ
Mailing Address - Zip Code:07876-1055
Mailing Address - Country:US
Mailing Address - Phone:973-584-7752
Mailing Address - Fax:
Practice Address - Street 1:1 CENTRAL AVENUE
Practice Address - Street 2:GREYSTONE PARK PSYCHIATRIC HOSPITAL
Practice Address - City:GREYSTONE PARK
Practice Address - State:NJ
Practice Address - Zip Code:07950
Practice Address - Country:US
Practice Address - Phone:973-538-1800
Practice Address - Fax:973-993-9081
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ026220207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJPR544388Medicare ID - Type Unspecified
NJE13563Medicare UPIN