Provider Demographics
NPI:1659668440
Name:PRASAD, PAVAN YARLAGADDARAGHU (MD)
Entity Type:Individual
Prefix:
First Name:PAVAN
Middle Name:YARLAGADDARAGHU
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 1:1 E SUPERIOR ST
Mailing Address - Street 2:SUITE 306
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2507
Mailing Address - Country:US
Mailing Address - Phone:312-754-9404
Mailing Address - Fax:
Practice Address - Street 1:1 E SUPERIOR ST
Practice Address - Street 2:SUITE 306
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2507
Practice Address - Country:US
Practice Address - Phone:312-754-9404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-30
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125-0604072084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry