Healthcare Provider Details

I. General information

NPI: 1467401042
Provider Name (Legal Business Name): VENU PRABAKER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 12/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7339 EL CAJON BLVD SUITE I
LA MESA CA
91941-3435
US

IV. Provider business mailing address

7339 EL CAJON BLVD SUITE I
LA MESA CA
91941-3435
US

V. Phone/Fax

Practice location:
  • Phone: 619-698-0606
  • Fax: 619-698-0609
Mailing address:
  • Phone: 619-698-0606
  • Fax: 619-698-0609

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA42653
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207RA0000X
TaxonomyAdolescent Medicine (Internal Medicine) Physician
License NumberA042653
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: