Provider Demographics
NPI:1609816859
Name:PROPHATER, ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:PROPHATER
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 1:55 ELVA CT
Mailing Address - Street 2:
Mailing Address - City:VANDALIA
Mailing Address - State:OH
Mailing Address - Zip Code:45377-1875
Mailing Address - Country:US
Mailing Address - Phone:937-208-7501
Mailing Address - Fax:937-208-7515
Practice Address - Street 1:55 ELVA CT
Practice Address - Street 2:
Practice Address - City:VANDALIA
Practice Address - State:OH
Practice Address - Zip Code:45377-1875
Practice Address - Country:US
Practice Address - Phone:937-208-7501
Practice Address - Fax:937-208-7515
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2011-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-03-7640-P207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0380485Medicaid
D31980Medicare UPIN
OH0412771Medicare PIN