Provider Demographics
NPI:1700800661
Name:PRASAD, RAGHAVENDRA S (MD)
Entity Type:Individual
Prefix:
First Name:RAGHAVENDRA
Middle Name:S
Last Name:PRASAD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 E FM 1382 #3354
Mailing Address - Street 2:
Mailing Address - City:CEDAR HILL
Mailing Address - State:TX
Mailing Address - Zip Code:75104
Mailing Address - Country:US
Mailing Address - Phone:214-325-1969
Mailing Address - Fax:972-291-0019
Practice Address - Street 1:445 E FM 1382 #3354
Practice Address - Street 2:
Practice Address - City:CEDAR HILL
Practice Address - State:TX
Practice Address - Zip Code:75104
Practice Address - Country:US
Practice Address - Phone:214-325-1969
Practice Address - Fax:972-291-0019
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ6213207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX148776103Medicaid
TX8F7027OtherINDIVIDUAL PTAN #/ ELLIS & COLLINS COUNTY
TX8F7028OtherINDIVIDUAL PTAN #/ TARRANT COUNTY
TX132640710Medicaid
TX8F7018OtherINDIVIDUAL PTAN/ DALLAS COUNTY
TX148776102Medicaid
TX132640710Medicaid
TX8C6637Medicare ID - Type Unspecified
TX8F7028OtherINDIVIDUAL PTAN #/ TARRANT COUNTY
TX8F7018OtherINDIVIDUAL PTAN/ DALLAS COUNTY