Provider Demographics
NPI:1497881700
Name:PRASAD, RAVI (PHD)
Entity Type:Individual
Prefix:
First Name:RAVI
Middle Name:
Last Name:PRASAD
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 BROADWAY ST
Mailing Address - Street 2:PAVILION C, MC 6343
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94063-3132
Mailing Address - Country:US
Mailing Address - Phone:650-723-6238
Mailing Address - Fax:
Practice Address - Street 1:450 BROADWAY ST
Practice Address - Street 2:PAVILION A, MC 5340
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94063-3132
Practice Address - Country:US
Practice Address - Phone:650-723-6238
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2011-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY19829103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY198290Medicaid
CAPSY198290Medicaid
CA0PL198290Medicare ID - Type Unspecified