Provider Demographics
NPI:1851365407
Name:PRASAD, JWALA (MD)
Entity Type:Individual
Prefix:DR
First Name:JWALA
Middle Name:
Last Name:PRASAD
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 1:5848 EXECUTIVE DRIVE
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48911
Mailing Address - Country:US
Mailing Address - Phone:517-882-8222
Mailing Address - Fax:517-882-5345
Practice Address - Street 1:5848 EXECUTIVE DRIVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48911
Practice Address - Country:US
Practice Address - Phone:517-882-8222
Practice Address - Fax:517-882-5345
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-13
Last Update Date:2009-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301036522207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI101344294Medicaid
MI0330506OtherBCBS
MI101344294Medicaid
2330006Medicare ID - Type Unspecified