Provider Demographics
NPI:1184696007
Name:PRAKASH, OM (MD)
Entity type:Individual
Prefix:
First Name:OM
Middle Name:
Last Name:PRAKASH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:18056 WIKA RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-2125
Mailing Address - Country:US
Mailing Address - Phone:760-242-2223
Mailing Address - Fax:760-242-1293
Practice Address - Street 1:18056 WIKA RD
Practice Address - Street 2:SUITE B
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-2125
Practice Address - Country:US
Practice Address - Phone:760-242-2223
Practice Address - Fax:760-242-1293
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-03
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA39024207VX0000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A390240Medicaid
CAA28795Medicare UPIN
CA00A390240Medicaid