Provider Demographics
NPI:1669769170
Name:PRAKASH, NEERA (MD)
Entity type:Individual
Prefix:
First Name:NEERA
Middle Name:
Last Name:PRAKASH
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 1:254 EASTON AVE
Mailing Address - Street 2:
Mailing Address - City:NEW BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08901-1766
Mailing Address - Country:US
Mailing Address - Phone:732-515-2063
Mailing Address - Fax:
Practice Address - Street 1:254 EASTON AVE
Practice Address - Street 2:
Practice Address - City:NEW BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08901
Practice Address - Country:US
Practice Address - Phone:732-515-2063
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-05
Last Update Date:2018-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA103621002080N0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103270479Medicaid