Provider Demographics
NPI:1689674665
Name:KILARU, PRASAD G
Entity Type:Individual
Prefix:
First Name:PRASAD
Middle Name:G
Last Name:KILARU
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 1:39141 CIVIC CENTER DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-1730
Mailing Address - Country:US
Mailing Address - Phone:510-791-9700
Mailing Address - Fax:510-791-9703
Practice Address - Street 1:39141 CIVIC CENTER DR
Practice Address - Street 2:SUITE 110
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1730
Practice Address - Country:US
Practice Address - Phone:510-791-9700
Practice Address - Fax:510-791-9703
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-29
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA0601042082S0105X, 208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A601040Medicaid
CA00A601040Medicare ID - Type Unspecified
CAG71216Medicare UPIN