Healthcare Provider Details

I. General information

NPI: 1912079294
Provider Name (Legal Business Name): PRAKASH P DEVASKAR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 RIVER DR
FORT BRAGG CA
95437-5403
US

IV. Provider business mailing address

700 RIVER DR
FORT BRAGG CA
95437-5403
US

V. Phone/Fax

Practice location:
  • Phone: 707-961-4631
  • Fax: 707-964-1192
Mailing address:
  • Phone: 707-961-4631
  • Fax: 707-964-1192

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberCA00A350680
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: