Provider Demographics
NPI:1972545093
Name:KUNAMNENI, PRABHAKARA (MD)
Entity Type:Individual
Prefix:
First Name:PRABHAKARA
Middle Name:
Last Name:KUNAMNENI
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 1289
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-1289
Mailing Address - Country:US
Mailing Address - Phone:352-343-1158
Mailing Address - Fax:352-343-8106
Practice Address - Street 1:1825 SALK AVE
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-4311
Practice Address - Country:US
Practice Address - Phone:352-343-1158
Practice Address - Fax:352-343-8106
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY223231207RC0000X
FLME101637207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001219100Medicaid
FL001219100Medicaid
FLAL841YMedicare PIN