Healthcare Provider Details

I. General information

NPI: 1659717965
Provider Name (Legal Business Name): NAMRATHA PRABHU M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2013
Last Update Date: 02/26/2021
Certification Date: 02/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5565 GROSSMONT CENTER DRIVE, BLDG. 3 SUITE 540
LA MESA CA
91942-3024
US

IV. Provider business mailing address

5565 GROSSMONT CENTER DRIVE, BLDG. 3 SUITE 540
LA MESA CA
91942-3024
US

V. Phone/Fax

Practice location:
  • Phone: 619-460-2700
  • Fax: 619-460-2702
Mailing address:
  • Phone: 619-460-2700
  • Fax: 619-460-2702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA153978
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberA153978
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: