Provider Demographics
NPI:1245645878
Name:PRABHU, ANGELINE
Entity type:Individual
Prefix:
First Name:ANGELINE
Middle Name:
Last Name:PRABHU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 SIXTH ST SW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44710-1702
Mailing Address - Country:US
Mailing Address - Phone:303-363-6223
Mailing Address - Fax:330-363-3877
Practice Address - Street 1:2435 FIRE MESA ST STE 120
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-9009
Practice Address - Country:US
Practice Address - Phone:702-968-2437
Practice Address - Fax:702-479-1796
Is Sole Proprietor?:No
Enumeration Date:2014-06-23
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NV21962207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program