Provider Demographics
NPI:1376647511
Name:RAO, PRAKASHCHANDRA M (MD)
Entity Type:Individual
Prefix:
First Name:PRAKASHCHANDRA
Middle Name:M
Last Name:RAO
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 1:3130 GRAND CONCOURSE
Mailing Address - Street 2:SUITE 1K
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10458-1213
Mailing Address - Country:US
Mailing Address - Phone:718-365-7255
Mailing Address - Fax:718-365-7558
Practice Address - Street 1:3130 GRAND CONCOURSE
Practice Address - Street 2:SUITE 1K
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10458-1213
Practice Address - Country:US
Practice Address - Phone:718-365-7255
Practice Address - Fax:718-365-7558
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2015-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY129784174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00764383Medicaid
NYC12339Medicare UPIN
NY92A262Medicare PIN