Healthcare Provider Details

I. General information

NPI: 1841425568
Provider Name (Legal Business Name): PRASHANTH PORAYETTE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2009
Last Update Date: 05/28/2024
Certification Date: 05/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25845 BARTON RD STE 101
LOMA LINDA CA
92354
US

IV. Provider business mailing address

25845 BARTON RD STE 101
LOMA LINDA CA
92354-5300
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-3904
  • Fax:
Mailing address:
  • Phone: 909-558-3904
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number036-138514
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License NumberC186822
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: