Provider Demographics
NPI:1740529049
Name:PRABAKAR, PRIYA PRAKASH (RD)
Entity type:Individual
Prefix:
First Name:PRIYA
Middle Name:PRAKASH
Last Name:PRABAKAR
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37710 CARRIAGE CIRCLE CMN
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94536-7076
Mailing Address - Country:US
Mailing Address - Phone:530-219-2628
Mailing Address - Fax:
Practice Address - Street 1:37710 CARRIAGE CIRCLE CMN
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94536-7076
Practice Address - Country:US
Practice Address - Phone:530-219-2628
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-06
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1056341133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered