Provider Demographics
NPI:1467482828
Name:PRABHAKAR, LAWRENCE P (MD)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:P
Last Name:PRABHAKAR
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 1:5668 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-2464
Mailing Address - Country:US
Mailing Address - Phone:815-229-7580
Mailing Address - Fax:815-229-7585
Practice Address - Street 1:5668 E STATE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2464
Practice Address - Country:US
Practice Address - Phone:815-229-7580
Practice Address - Fax:815-229-7585
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036098121208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036098121Medicaid
280000796OtherRAILROAD MEDICARE
WI32473900Medicaid
448800Medicare ID - Type Unspecified
280000796OtherRAILROAD MEDICARE