Provider Demographics
NPI:1841671757
Name:PRABHU, SACHIDANAND (MD)
Entity type:Individual
Prefix:
First Name:SACHIDANAND
Middle Name:
Last Name:PRABHU
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 1:4601 DALE RD
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356-9718
Mailing Address - Country:US
Mailing Address - Phone:209-564-3500
Mailing Address - Fax:
Practice Address - Street 1:315 MERCY AVE STE 301
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95340-8367
Practice Address - Country:US
Practice Address - Phone:209-564-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-16
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA139532207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine