Provider Demographics
NPI:1720004393
Name:PRABHAKARAN, VINAY (MD)
Entity Type:Individual
Prefix:
First Name:VINAY
Middle Name:
Last Name:PRABHAKARAN
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 1:8328 E. HARTFORD DR.
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85255
Mailing Address - Country:US
Mailing Address - Phone:502-637-1005
Mailing Address - Fax:502-635-0046
Practice Address - Street 1:8328 E. HARTFORD DR.
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85255
Practice Address - Country:US
Practice Address - Phone:480-214-9720
Practice Address - Fax:480-214-9722
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY38813207R00000X
AZ40421207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000336564OtherANTHEM FACETS PIN
AZ352442Medicaid
KY64083587Medicaid
KY0380119Medicare PIN
AZ352442Medicaid
KYP00190081Medicare PIN
KYI11428Medicare UPIN
KY64083587Medicaid
2140424Medicare PIN