Provider Demographics
NPI:1619959665
Name:POLICHERLA, PRASAD N
Entity Type:Individual
Prefix:DR
First Name:PRASAD
Middle Name:N
Last Name:POLICHERLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:DEFIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:43512-2440
Mailing Address - Country:US
Mailing Address - Phone:419-784-1414
Mailing Address - Fax:
Practice Address - Street 1:1400 E 2ND ST
Practice Address - Street 2:
Practice Address - City:DEFIANCE
Practice Address - State:OH
Practice Address - Zip Code:43512-2440
Practice Address - Country:US
Practice Address - Phone:419-784-1414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2010-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350654572084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH130020927OtherRAILROAD
OH2123473Medicaid
OH0881962Medicare PIN
OHPO0881961Medicare PIN
OH2123473Medicaid