Provider Demographics
NPI:1770666208
Name:MALVIYA, PRAKASH (MD)
Entity Type:Individual
Prefix:
First Name:PRAKASH
Middle Name:
Last Name:MALVIYA
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 1:409 COTTAGE ROAD
Mailing Address - Street 2:ETMC
Mailing Address - City:CARTHAGE
Mailing Address - State:TX
Mailing Address - Zip Code:75633
Mailing Address - Country:US
Mailing Address - Phone:903-694-4790
Mailing Address - Fax:
Practice Address - Street 1:409 COTTAGE ROAD
Practice Address - Street 2:ETMC
Practice Address - City:CARTHAGE
Practice Address - State:TX
Practice Address - Zip Code:75633
Practice Address - Country:US
Practice Address - Phone:903-694-4790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2011-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY189949208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYCAREPLUSOther189949
NY01553277Medicaid
NY01553277Medicaid