Provider Demographics
NPI:1578792289
Name:PRABHAKARAN, AILEEN R (MD)
Entity Type:Individual
Prefix:
First Name:AILEEN
Middle Name:R
Last Name:PRABHAKARAN
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 1:600 1ST ST NW STE 101
Mailing Address - Street 2:
Mailing Address - City:MASON CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50401-2932
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:910 N EISENHOWER AVE
Practice Address - Street 2:
Practice Address - City:MASON CITY
Practice Address - State:IA
Practice Address - Zip Code:50401-1525
Practice Address - Country:US
Practice Address - Phone:641-428-7799
Practice Address - Fax:641-428-5274
Is Sole Proprietor?:No
Enumeration Date:2009-07-02
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA41250207Q00000X
IAR-8756207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0230169Medicaid
IA0230169Medicaid