Provider Demographics
NPI:1568465854
Name:PRADHAN, PRADEEP K (MD)
Entity Type:Individual
Prefix:DR
First Name:PRADEEP
Middle Name:K
Last Name:PRADHAN
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 1:414 PARK AVE
Mailing Address - Street 2:STE F
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24541-4630
Mailing Address - Country:US
Mailing Address - Phone:434-857-3600
Mailing Address - Fax:434-200-1654
Practice Address - Street 1:414 PARK AVE
Practice Address - Street 2:STE F
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541-4630
Practice Address - Country:US
Practice Address - Phone:434-857-3600
Practice Address - Fax:434-200-1654
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101053120207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA280236OtherANTHEM
VA5811104Medicaid
VA5811104Medicaid
VAG06259Medicare UPIN
VA110006816Medicare ID - Type Unspecified