Provider Demographics
NPI:1952308777
Name:PRASAD, RITESH R (MD)
Entity Type:Individual
Prefix:DR
First Name:RITESH
Middle Name:R
Last Name:PRASAD
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:PO BOX 130940
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75713-0940
Mailing Address - Country:US
Mailing Address - Phone:903-593-9999
Mailing Address - Fax:903-526-2679
Practice Address - Street 1:3110 PARK CENTER DR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-9215
Practice Address - Country:US
Practice Address - Phone:903-593-9999
Practice Address - Fax:903-526-2679
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2012-06-11
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-03-29
Provider Licenses
StateLicense IDTaxonomies
TXK1283208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX710882255OtherEIN
TX710882255OtherEIN
TX8803B0Medicare ID - Type Unspecified