Provider Demographics
NPI:1760624605
Name:ATHYALA, PRASANNA K
Entity Type:Individual
Prefix:MR
First Name:PRASANNA
Middle Name:K
Last Name:ATHYALA
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 1:415 N JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-5124
Mailing Address - Country:US
Mailing Address - Phone:432-333-1837
Mailing Address - Fax:432-333-1856
Practice Address - Street 1:415 N JACKSON AVE
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-5124
Practice Address - Country:US
Practice Address - Phone:432-333-1837
Practice Address - Fax:432-333-1856
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-24
Last Update Date:2009-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RM2200XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyMedical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXCL8556Medicare PIN