Provider Demographics
NPI:1891822268
Name:MRIDULA PRASAD MD PC
Entity Type:Organization
Organization Name:MRIDULA PRASAD MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MRIDULA
Authorized Official - Middle Name:
Authorized Official - Last Name:PRASAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-836-0039
Mailing Address - Street 1:9250 COLUMBIA AVE STE 1C
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-3530
Mailing Address - Country:US
Mailing Address - Phone:219-836-0039
Mailing Address - Fax:219-836-0288
Practice Address - Street 1:9250 COLUMBIA AVE STE 1C
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-3530
Practice Address - Country:US
Practice Address - Phone:219-836-0039
Practice Address - Fax:219-836-0288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN2084N0400X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000103391OtherBCBS IN
91108099OtherBCBS IL
91108099OtherBCBS IL
IN627360Medicare ID - Type Unspecified