Provider Demographics
NPI:1700958873
Name:VANKINENI, PRASAD S (MD)
Entity Type:Individual
Prefix:
First Name:PRASAD
Middle Name:S
Last Name:VANKINENI
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 1:420 LOWELL DRIVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801-3763
Mailing Address - Country:US
Mailing Address - Phone:256-536-9031
Mailing Address - Fax:256-539-4240
Practice Address - Street 1:420 LOWELL DR.
Practice Address - Street 2:SUITE 204
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-3763
Practice Address - Country:US
Practice Address - Phone:256-536-9031
Practice Address - Fax:256-539-4240
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AL10838207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000011586Medicaid
AL000011586Medicaid
AL000011586Medicare PIN