Provider Demographics
NPI:1568899474
Name:PRABHU, ROSHAN D (MD)
Entity Type:Individual
Prefix:DR
First Name:ROSHAN
Middle Name:D
Last Name:PRABHU
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 1:640 S. STATE STREET
Mailing Address - Street 2:MAIL CODE 3055
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19901-3530
Mailing Address - Country:US
Mailing Address - Phone:302-480-1688
Mailing Address - Fax:302-480-9807
Practice Address - Street 1:1074 S STATE ST
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19901-6925
Practice Address - Country:US
Practice Address - Phone:302-725-3214
Practice Address - Fax:302-725-3215
Is Sole Proprietor?:No
Enumeration Date:2013-10-09
Last Update Date:2021-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0010974207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine