Provider Demographics
NPI:1497742423
Name:PRASAD, SHISHIR C (MD FACS)
Entity Type:Individual
Prefix:DR
First Name:SHISHIR
Middle Name:C
Last Name:PRASAD
Suffix:
Gender:M
Credentials:MD FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 CAREY LN
Mailing Address - Street 2:
Mailing Address - City:PITTSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18640-3224
Mailing Address - Country:US
Mailing Address - Phone:570-654-2550
Mailing Address - Fax:
Practice Address - Street 1:14 CAREY LN
Practice Address - Street 2:
Practice Address - City:PITTSTON
Practice Address - State:PA
Practice Address - Zip Code:18640-3224
Practice Address - Country:US
Practice Address - Phone:570-654-2550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-04
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD033494L208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0006086470005Medicaid
C32846Medicare UPIN
PAPR175590Medicare ID - Type Unspecified