Provider Demographics
NPI:1275735789
Name:PANDALAI, PRAKASH (MD)
Entity Type:Individual
Prefix:
First Name:PRAKASH
Middle Name:
Last Name:PANDALAI
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 1:8008 WESTPARK DR
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22102-3109
Mailing Address - Country:US
Mailing Address - Phone:240-330-9506
Mailing Address - Fax:
Practice Address - Street 1:800 ROSE ST
Practice Address - Street 2:1ST FL
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536
Practice Address - Country:US
Practice Address - Phone:859-323-6542
Practice Address - Fax:859-323-2074
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-05
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35085025208600000X
KYTP5942086X0206X
KY530952086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
No208600000XAllopathic & Osteopathic PhysiciansSurgery