Provider Demographics
NPI:1245343250
Name:PRAKASH, SHIVANHALLI (MD)
Entity type:Individual
Prefix:
First Name:SHIVANHALLI
Middle Name:
Last Name:PRAKASH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:SHIVANA
Other - Middle Name:
Other - Last Name:PRAKASH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:43311 COMMONS DRIVE
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1109
Mailing Address - Country:US
Mailing Address - Phone:586-263-8555
Mailing Address - Fax:586-263-8558
Practice Address - Street 1:43311 COMMONS DR
Practice Address - Street 2:
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48038-1109
Practice Address - Country:US
Practice Address - Phone:586-263-8555
Practice Address - Fax:586-263-8558
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISP407447208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery