Provider Demographics
NPI:1497775977
Name:PRASAD P PERUMBETI MD, INC.
Entity Type:Organization
Organization Name:PRASAD P PERUMBETI MD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PRASAD
Authorized Official - Middle Name:P
Authorized Official - Last Name:PERUMBETI V
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-835-1500
Mailing Address - Street 1:PO BOX 7156
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95267-0156
Mailing Address - Country:US
Mailing Address - Phone:209-467-6866
Mailing Address - Fax:209-467-6865
Practice Address - Street 1:1420 N TRACY BLVD
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376-3451
Practice Address - Country:US
Practice Address - Phone:209-835-1500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2008-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC51681207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C516810Medicaid
CAZZZ01873ZMedicare ID - Type Unspecified
CA00C516810Medicaid