Provider Demographics
NPI:1821067778
Name:PRABHAKAR, BALAKRISHNA R (MD)
Entity Type:Individual
Prefix:
First Name:BALAKRISHNA
Middle Name:R
Last Name:PRABHAKAR
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 1:8806 N NAVARRO ST STE 600
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77904-1564
Mailing Address - Country:US
Mailing Address - Phone:361-485-2695
Mailing Address - Fax:361-485-0635
Practice Address - Street 1:1259 FM 1463 RD STE 400
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77494-5480
Practice Address - Country:US
Practice Address - Phone:713-429-4550
Practice Address - Fax:832-397-6426
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV19872208000000X, 207R00000X
TXN 1075207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001720356OtherMS BCBS
WV6000462000Medicaid
TXN1075OtherMEDICAL LICENSE
TXN1075OtherMEDICAL LICENSE
WV6000462000Medicaid
WVH03568Medicare UPIN
WV0890727Medicare PIN