Provider Demographics
NPI:1861492118
Name:CHARIYA, PRASAN (MD)
Entity Type:Individual
Prefix:
First Name:PRASAN
Middle Name:
Last Name:CHARIYA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:PRASAN
Other - Middle Name:
Other - Last Name:CHARIYASHOTILERT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD SC
Mailing Address - Street 1:3522 49TH ST
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6656
Mailing Address - Country:US
Mailing Address - Phone:309-762-6949
Mailing Address - Fax:
Practice Address - Street 1:3522 49TH ST
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6656
Practice Address - Country:US
Practice Address - Phone:309-762-6949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2007-07-08
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
IL207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILE30205Medicare UPIN