Provider Demographics
NPI:1689647562
Name:PRABHAKAR, SHYLAJA (MD)
Entity Type:Individual
Prefix:DR
First Name:SHYLAJA
Middle Name:
Last Name:PRABHAKAR
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 1:2618 RIDGEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31707-3057
Mailing Address - Country:US
Mailing Address - Phone:229-431-0998
Mailing Address - Fax:
Practice Address - Street 1:2025 PALMYRA RD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31701-1576
Practice Address - Country:US
Practice Address - Phone:229-888-7332
Practice Address - Fax:229-888-2426
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA042699207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00727779BMedicaid
GA11BDMMFMedicare ID - Type Unspecified
GAF93456Medicare UPIN