Provider Demographics
NPI:1740253517
Name:SRINIVASAN, PRASAD (MD)
Entity type:Individual
Prefix:DR
First Name:PRASAD
Middle Name:
Last Name:SRINIVASAN
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 1:622 HEBRON AVE STE 104B
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-5003
Mailing Address - Country:US
Mailing Address - Phone:860-659-8904
Mailing Address - Fax:860-246-5828
Practice Address - Street 1:622 HEBRON AVE STE 104B
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-5003
Practice Address - Country:US
Practice Address - Phone:860-659-8904
Practice Address - Fax:860-246-5828
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT022206207KA0200X, 207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT030000070OtherMEDICARE ID
CT001222066Medicaid
CTC00280OtherMEDICARE
CT001222066Medicaid
CT001222066Medicaid