Provider Demographics
NPI:1366482580
Name:PRACHUN, PAUL (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:PRACHUN
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 1:100 E CAMPUS VIEW BLVD
Mailing Address - Street 2:STE 160
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43235-4647
Mailing Address - Country:US
Mailing Address - Phone:614-396-4750
Mailing Address - Fax:614-396-4742
Practice Address - Street 1:401 MATTHEW ST
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-1635
Practice Address - Country:US
Practice Address - Phone:740-374-1410
Practice Address - Fax:740-374-1691
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350637572085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
300063737OtherMEDICARE RAILROAD
WV0119372000Medicaid
OH0891290Medicaid
300063737OtherMEDICARE RAILROAD
PR0724921Medicare ID - Type Unspecified