Healthcare Provider Details

I. General information

NPI: 1174956270
Provider Name (Legal Business Name): RAVINDRA PRABHU MD A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2013
Last Update Date: 09/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

754 MEDICAL CENTER CT. SUITE 206
CHULA VISTA CA
91911-6656
US

IV. Provider business mailing address

754 MEDICAL CENTER CT. SUITE 206
CHULA VISTA CA
91911-6656
US

V. Phone/Fax

Practice location:
  • Phone: 619-482-4333
  • Fax: 619-482-4445
Mailing address:
  • Phone: 619-482-4333
  • Fax: 619-482-4445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License NumberA37174
License Number StateCA

VIII. Authorized Official

Name: RAVINDRA PRABHU
Title or Position: MD.
Credential: MD
Phone: 619-482-4333