Provider Demographics
NPI:1801411657
Name:PRABHU, ABHISHEK (DO)
Entity type:Individual
Prefix:
First Name:ABHISHEK
Middle Name:
Last Name:PRABHU
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 1:608 UNION CHAPEL RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-9357
Mailing Address - Country:US
Mailing Address - Phone:248-875-6735
Mailing Address - Fax:
Practice Address - Street 1:207 N TOWNLINE RD
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:IN
Practice Address - Zip Code:46761-1325
Practice Address - Country:US
Practice Address - Phone:260-482-4440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-08
Last Update Date:2024-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5151014320207P00000X
IN02006789A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine