Provider Demographics
NPI:1952319477
Name:ATHOTA, PRASAD J (MD)
Entity Type:Individual
Prefix:DR
First Name:PRASAD
Middle Name:J
Last Name:ATHOTA
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 497
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:AR
Mailing Address - Zip Code:72006-0497
Mailing Address - Country:US
Mailing Address - Phone:870-347-2534
Mailing Address - Fax:870-347-3492
Practice Address - Street 1:615 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BRINKLEY
Practice Address - State:AR
Practice Address - Zip Code:72021-2507
Practice Address - Country:US
Practice Address - Phone:870-347-2534
Practice Address - Fax:870-347-3492
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR4382207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR122705001Medicaid
AR57297Medicare PIN
AR122705001Medicaid
AR56539Medicare PIN