Provider Demographics
NPI:1639198054
Name:PRASAD, MADAN (MD)
Entity Type:Individual
Prefix:
First Name:MADAN
Middle Name:
Last Name:PRASAD
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:PO BOX 7393
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95267-0393
Mailing Address - Country:US
Mailing Address - Phone:209-951-8830
Mailing Address - Fax:209-951-8831
Practice Address - Street 1:1801 E MARCH LN
Practice Address - Street 2:SUITE B-220
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95210-6629
Practice Address - Country:US
Practice Address - Phone:209-951-8830
Practice Address - Fax:209-951-8831
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2013-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA866002084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A866000Medicaid
CA00A866000Medicare PIN
CA00A866000Medicaid