Provider Demographics
NPI:1942449780
Name:RATHI, PRABODH DEOKARANJI (MD)
Entity Type:Individual
Prefix:DR
First Name:PRABODH
Middle Name:DEOKARANJI
Last Name:RATHI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 GREEN VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:FREEDOM
Mailing Address - State:CA
Mailing Address - Zip Code:95019-3110
Mailing Address - Country:US
Mailing Address - Phone:831-319-4194
Mailing Address - Fax:831-319-4197
Practice Address - Street 1:108 GREEN VALLEY RD
Practice Address - Street 2:
Practice Address - City:FREEDOM
Practice Address - State:CA
Practice Address - Zip Code:95019-3110
Practice Address - Country:US
Practice Address - Phone:831-319-4194
Practice Address - Fax:831-319-4197
Is Sole Proprietor?:No
Enumeration Date:2009-02-18
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ41376207R00000X
CA122987207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
031822Medicare Oscar/Certification
031823Medicare Oscar/Certification
Z21115Medicare PIN
Z21130Medicare PIN
031805Medicare Oscar/Certification
Z21116Medicare PIN
031824Medicare Oscar/Certification
Z21114Medicare PIN
Z21113Medicare PIN
Z21116Medicare PIN