Provider Demographics
NPI:1972678845
Name:PRASANNA, PRASANTH M (MD)
Entity Type:Individual
Prefix:DR
First Name:PRASANTH
Middle Name:M
Last Name:PRASANNA
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 1:1400 SW 5TH AVE STE 500
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97201-5537
Mailing Address - Country:US
Mailing Address - Phone:503-494-8417
Mailing Address - Fax:503-494-4455
Practice Address - Street 1:335 SE 8TH AVE
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-4246
Practice Address - Country:US
Practice Address - Phone:503-681-1100
Practice Address - Fax:503-681-1835
Is Sole Proprietor?:No
Enumeration Date:2006-11-23
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD1563652085R0202X
MDD700832085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500641671Medicaid
OR500641671Medicaid