Provider Demographics
NPI:1649235409
Name:PRAKASH, SOORDAL O (MD)
Entity type:Individual
Prefix:DR
First Name:SOORDAL
Middle Name:O
Last Name:PRAKASH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5937 BENEVA RD
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34238-2504
Mailing Address - Country:US
Mailing Address - Phone:941-918-2011
Mailing Address - Fax:941-918-2046
Practice Address - Street 1:5937 BENEVA RD
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34238-2504
Practice Address - Country:US
Practice Address - Phone:941-918-2011
Practice Address - Fax:941-918-2046
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME76860207QG0300X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
4106534005OtherCIGNA
FL29060OtherBCBS
FL7119242OtherAETNA
245078OtherWELLCARE MCARE
FL266978100Medicaid
FL29060OtherBCBS
FL266978100Medicaid
4106534005OtherCIGNA