Provider Demographics
NPI:1326057597
Name:ETTIGI, PRAKASH G (MD)
Entity Type:Individual
Prefix:DR
First Name:PRAKASH
Middle Name:G
Last Name:ETTIGI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1395 NW 167TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33169-5710
Mailing Address - Country:US
Mailing Address - Phone:305-628-6117
Mailing Address - Fax:
Practice Address - Street 1:6530 HULL STREET RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23224
Practice Address - Country:US
Practice Address - Phone:804-674-3425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-06
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010288342084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAB59715Medicare UPIN