Healthcare Provider Details

I. General information

NPI: 1932593167
Provider Name (Legal Business Name): VIJAY KRISHNA PRABHAKAR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2015
Last Update Date: 10/22/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1837 SUNNY CREST DR
FULLERTON CA
92835-3616
US

IV. Provider business mailing address

1837 SUNNY CREST DR
FULLERTON CA
92835-3616
US

V. Phone/Fax

Practice location:
  • Phone: 714-446-5831
  • Fax:
Mailing address:
  • Phone: 714-446-5831
  • Fax: 714-446-7910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberA144053
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: