Provider Demographics
NPI:1467401042
Name:PRABAKER, VENU (MD)
Entity Type:Individual
Prefix:DR
First Name:VENU
Middle Name:
Last Name:PRABAKER
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 1:7339 EL CAJON BLVD
Mailing Address - Street 2:SUITE I
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91941-3435
Mailing Address - Country:US
Mailing Address - Phone:619-698-0606
Mailing Address - Fax:619-698-0609
Practice Address - Street 1:7339 EL CAJON BLVD
Practice Address - Street 2:SUITE I
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91941-3435
Practice Address - Country:US
Practice Address - Phone:619-698-0606
Practice Address - Fax:619-698-0609
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-09
Last Update Date:2017-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA42653174400000X
CAA042653207RA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC03072Medicare UPIN