Healthcare Provider Details

I. General information

NPI: 1396710075
Provider Name (Legal Business Name): ARUDI L PRABHAKAR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 05/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6136 LAKE MURRAY BLVD
LA MESA CA
91942-2502
US

IV. Provider business mailing address

18231 IRVINE BLVD STE 204
TUSTIN CA
92780-3432
US

V. Phone/Fax

Practice location:
  • Phone: 619-303-5500
  • Fax: 619-303-5595
Mailing address:
  • Phone: 714-389-5700
  • Fax: 714-389-6973

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA31627
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: