Provider Demographics
NPI:1942206545
Name:PRASAD, SUJATHA (MD)
Entity Type:Individual
Prefix:DR
First Name:SUJATHA
Middle Name:
Last Name:PRASAD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SUJATHA
Other - Middle Name:
Other - Last Name:NATWA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2298 SPRINGPORT RD
Mailing Address - Street 2:STE B
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49202-1475
Mailing Address - Country:US
Mailing Address - Phone:517-784-3950
Mailing Address - Fax:517-817-1681
Practice Address - Street 1:2200 SPRINGPORT RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-1432
Practice Address - Country:US
Practice Address - Phone:517-784-9356
Practice Address - Fax:517-780-9286
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301060650207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4744226-10Medicaid
MIG54284Medicare UPIN
MI4744226-10Medicaid