Healthcare Provider Details

I. General information

NPI: 1144204462
Provider Name (Legal Business Name): MADHU PRASAD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 05/13/2021
Certification Date: 05/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2925 DEBARR RD STE D350
ANCHORAGE AK
99508-2959
US

IV. Provider business mailing address

PO BOX 75060
CHICAGO IL
60690-6310
US

V. Phone/Fax

Practice location:
  • Phone: 907-276-3676
  • Fax: 907-276-3679
Mailing address:
  • Phone: 907-276-3676
  • Fax: 907-276-3679

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number155056
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number155056
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: