Provider Demographics
NPI:1841425568
Name:PORAYETTE, PRASHANTH (MD)
Entity type:Individual
Prefix:DR
First Name:PRASHANTH
Middle Name:
Last Name:PORAYETTE
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 1:25845 BARTON RD STE 101
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-5300
Mailing Address - Country:US
Mailing Address - Phone:909-558-3904
Mailing Address - Fax:
Practice Address - Street 1:25845 BARTON RD STE 101
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354
Practice Address - Country:US
Practice Address - Phone:909-558-3904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-26
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-1385142080P0206X
CAC1868222080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036138514Medicaid
ILF400236795Medicare PIN