Provider Demographics
NPI:1659332724
Name:PRADHAN, PEMALA (MD)
Entity Type:Individual
Prefix:
First Name:PEMALA
Middle Name:
Last Name:PRADHAN
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 1:5160 MACCLENTHEN RD
Mailing Address - Street 2:
Mailing Address - City:MANLIUS
Mailing Address - State:NY
Mailing Address - Zip Code:13104-8423
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4900 BROAD RD
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13215-2265
Practice Address - Country:US
Practice Address - Phone:315-492-5772
Practice Address - Fax:315-433-1325
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-29
Last Update Date:2009-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1362822084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00635543Medicaid
NYC59005Medicare UPIN
NY37965BMedicare ID - Type Unspecified