Provider Demographics
NPI:1912201435
Name:PRAKASH, DAVE (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVE
Middle Name:
Last Name:PRAKASH
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:PO BOX 184
Mailing Address - Street 2:
Mailing Address - City:BARKSDALE AFB
Mailing Address - State:LA
Mailing Address - Zip Code:71110-0184
Mailing Address - Country:US
Mailing Address - Phone:315-882-2278
Mailing Address - Fax:
Practice Address - Street 1:5526 LAKE SIDE DR
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-5504
Practice Address - Country:US
Practice Address - Phone:315-882-2278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-23
Last Update Date:2010-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY234586261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center