Provider Demographics
NPI:1548410574
Name:SIMHADRI, PRATHAP KUMAR (MD)
Entity Type:Individual
Prefix:
First Name:PRATHAP KUMAR
Middle Name:
Last Name:SIMHADRI
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 1:301 MEMORIAL MEDICAL PKWY
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-5167
Mailing Address - Country:US
Mailing Address - Phone:386-231-1091
Mailing Address - Fax:386-231-1092
Practice Address - Street 1:305 MEMORIAL MEDICAL PKWY
Practice Address - Street 2:STE 507
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-5168
Practice Address - Country:US
Practice Address - Phone:386-672-8595
Practice Address - Fax:386-677-4987
Is Sole Proprietor?:No
Enumeration Date:2008-09-26
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME121973207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014218100Medicaid
GA202I118406Medicare PIN