Provider Demographics
NPI:1780082693
Name:MYNENI, BANU PRASAD (DO)
Entity type:Individual
Prefix:DR
First Name:BANU
Middle Name:PRASAD
Last Name:MYNENI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3235 ACADEMY AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23703-3200
Mailing Address - Country:US
Mailing Address - Phone:757-484-7386
Mailing Address - Fax:757-484-1913
Practice Address - Street 1:3235 ACADEMY AVE STE 101
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23703-3200
Practice Address - Country:US
Practice Address - Phone:757-484-7386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-09
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-144866207Q00000X
VA0102206019207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine