Provider Demographics
NPI:1659439230
Name:PRABHU, MANJESHWAR RAMAKRISHNA (MD)
Entity Type:Individual
Prefix:
First Name:MANJESHWAR
Middle Name:RAMAKRISHNA
Last Name:PRABHU
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 1:1147 BRITTMOORE RD, SUITE 4
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77043-8103
Mailing Address - Country:US
Mailing Address - Phone:713-960-0344
Mailing Address - Fax:713-871-9517
Practice Address - Street 1:1147 BRITTMOORE RD STE 4
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77043-5039
Practice Address - Country:US
Practice Address - Phone:713-960-0344
Practice Address - Fax:713-871-9517
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG73072084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX113910702Medicaid
760248938OtherTIN
C20659Medicare UPIN
TXPR000A67CMedicare ID - Type Unspecified