Provider Demographics
NPI:1609945427
Name:PANTHAGANI, PRASAD B (MD)
Entity Type:Individual
Prefix:DR
First Name:PRASAD
Middle Name:B
Last Name:PANTHAGANI
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 1:701 COTTAGE GROVE ROAD
Mailing Address - Street 2:SUITE B210
Mailing Address - City:BLOOMFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06002
Mailing Address - Country:US
Mailing Address - Phone:860-242-9191
Mailing Address - Fax:860-242-9090
Practice Address - Street 1:701 COTTAGE GROVE RD
Practice Address - Street 2:SUITE B210
Practice Address - City:BLOOMFIELD
Practice Address - State:CT
Practice Address - Zip Code:06002-3080
Practice Address - Country:US
Practice Address - Phone:860-242-9090
Practice Address - Fax:860-242-9191
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT044859207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001448598Medicaid
NYH49924Medicare UPIN