Provider Demographics
NPI:1417027103
Name:DEVABHAKTUNI, PRASAD VENKATA (MD)
Entity Type:Individual
Prefix:DR
First Name:PRASAD
Middle Name:VENKATA
Last Name:DEVABHAKTUNI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:14 E GRAFTON RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-4465
Mailing Address - Country:US
Mailing Address - Phone:304-363-7773
Mailing Address - Fax:304-363-7773
Practice Address - Street 1:14 E GRAFTON RD
Practice Address - Street 2:SUITE C
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-4465
Practice Address - Country:US
Practice Address - Phone:304-363-7773
Practice Address - Fax:304-363-7773
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV15587207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0009095000Medicaid
WV0071632000Medicaid
WV0071632000Medicaid
WVD49448Medicare UPIN
WV0009095000Medicaid