Provider Demographics
NPI:1831277714
Name:MUMMANENI, PRASAD D (MD)
Entity type:Individual
Prefix:MR
First Name:PRASAD
Middle Name:D
Last Name:MUMMANENI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:PRASAD
Other - Middle Name:DURGA
Other - Last Name:MUMMANENI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1700 NORTH ROSE AVENUE
Mailing Address - Street 2:SUITE 350
Mailing Address - City:OXNARD
Mailing Address - State:CA
Mailing Address - Zip Code:93030
Mailing Address - Country:US
Mailing Address - Phone:805-983-0208
Mailing Address - Fax:805-981-0565
Practice Address - Street 1:1700 NORTH ROSE AVENUE
Practice Address - Street 2:SUITE 350
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93030
Practice Address - Country:US
Practice Address - Phone:805-983-0208
Practice Address - Fax:805-981-0565
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA35782207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA35782OtherSTATE LIC
CA00A357820Medicaid
CA00A357820Medicaid
CA00A357820Medicaid
WA35782AMedicare ID - Type Unspecified