Provider Demographics
NPI:1578524898
Name:PRASAD, MRIDULA (MD)
Entity Type:Individual
Prefix:
First Name:MRIDULA
Middle Name:
Last Name:PRASAD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9250 COLUMBIA AVE
Mailing Address - Street 2:SUITE C1
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-3538
Mailing Address - Country:US
Mailing Address - Phone:219-836-0039
Mailing Address - Fax:219-836-0288
Practice Address - Street 1:9250 COLUMBIA AVE
Practice Address - Street 2:SUITE C1
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-3538
Practice Address - Country:US
Practice Address - Phone:219-836-0039
Practice Address - Fax:219-836-0288
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-28
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010324462084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100340470BMedicaid
IN100340470BMedicaid
IN627360Medicare ID - Type Unspecified