Provider Demographics
NPI:1619292331
Name:PRAKASH, NISHA ANU (MD)
Entity Type:Individual
Prefix:
First Name:NISHA
Middle Name:ANU
Last Name:PRAKASH
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:PO BOX 755
Mailing Address - Street 2:
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560-0755
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 W 16TH ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2745
Practice Address - Country:US
Practice Address - Phone:719-584-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-06
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0054281208M00000X
NE28858208M00000X
MN107174208M00000X
PAMD447004208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist