Provider Demographics
NPI:1568450211
Name:JAYAPRAKASH, SUBBANNA (MD)
Entity Type:Individual
Prefix:DR
First Name:SUBBANNA
Middle Name:
Last Name:JAYAPRAKASH
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 1:7401 LATIGO CIR
Mailing Address - Street 2:
Mailing Address - City:FRANKSVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53126-9468
Mailing Address - Country:US
Mailing Address - Phone:262-886-6252
Mailing Address - Fax:
Practice Address - Street 1:3811 SPRING ST
Practice Address - Street 2:SUITE 301
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53405-1667
Practice Address - Country:US
Practice Address - Phone:262-687-6262
Practice Address - Fax:262-687-6261
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIO27676208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI314772200Medicaid
D 87506Medicare UPIN