Provider Demographics
NPI:1689140634
Name:KAKARLA, PRABHASH
Entity Type:Individual
Prefix:
First Name:PRABHASH
Middle Name:
Last Name:KAKARLA
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 1:2302 LONE STAR RD STE 200
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-8751
Mailing Address - Country:US
Mailing Address - Phone:682-341-7200
Mailing Address - Fax:682-341-7201
Practice Address - Street 1:2302 LONE STAR RD STE 200
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-8751
Practice Address - Country:US
Practice Address - Phone:682-341-7200
Practice Address - Fax:682-341-7201
Is Sole Proprietor?:No
Enumeration Date:2018-10-17
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY314513207R00000X
390200000X
TXU1046207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program