Provider Demographics
NPI:1952446155
Name:PRABHAKARIAN, JOHN DESARAJ
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:DESARAJ
Last Name:PRABHAKARIAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JOHN
Other - Middle Name:DESARAJ
Other - Last Name:PRABHAKARIAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:12760 WESTWOOD LAKES BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33626-2345
Mailing Address - Country:US
Mailing Address - Phone:813-855-9791
Mailing Address - Fax:
Practice Address - Street 1:12760 WESTWOOD LAKES BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626-2345
Practice Address - Country:US
Practice Address - Phone:813-855-9791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2009-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT2852225X00000X
222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL884490900Medicaid