Provider Demographics
NPI:1508495383
Name:PRABAKARAN, PRASHANTH JYOTHI (MD)
Entity Type:Individual
Prefix:
First Name:PRASHANTH
Middle Name:JYOTHI
Last Name:PRABAKARAN
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 1:2585 UNIVERSITY AVE APT 215
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705-3815
Mailing Address - Country:US
Mailing Address - Phone:608-628-3514
Mailing Address - Fax:
Practice Address - Street 1:4201 ST. ANTOINE
Practice Address - Street 2:5E-UHC
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201
Practice Address - Country:US
Practice Address - Phone:608-628-3514
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-03
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program