Provider Demographics
NPI:1417038746
Name:PREM, SUNIL (MD)
Entity Type:Individual
Prefix:DR
First Name:SUNIL
Middle Name:
Last Name:PREM
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:PO BOX 7500
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71211-7500
Mailing Address - Country:US
Mailing Address - Phone:318-388-0440
Mailing Address - Fax:318-388-0330
Practice Address - Street 1:1503 STUBBS AVE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-5627
Practice Address - Country:US
Practice Address - Phone:318-388-0440
Practice Address - Fax:318-388-0330
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAL12718R207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1542555Medicaid
LA1542555Medicaid
LA5A746Medicare ID - Type Unspecified