Provider Demographics
NPI:1013083781
Name:PRASAD, SUDHA R (MD)
Entity Type:Individual
Prefix:DR
First Name:SUDHA
Middle Name:R
Last Name:PRASAD
Suffix:
Gender:F
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 17962
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38187-7962
Mailing Address - Country:US
Mailing Address - Phone:901-324-3984
Mailing Address - Fax:901-454-1655
Practice Address - Street 1:3836 PARK AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38111-6633
Practice Address - Country:US
Practice Address - Phone:901-324-3984
Practice Address - Fax:901-454-1655
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN12949207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3183447Medicaid
TN25923OtherBLUE CROSS BLUE SHIELD
TN3183447Medicaid
TN3183447Medicare ID - Type Unspecified