Healthcare Provider Details

I. General information

NPI: 1104123165
Provider Name (Legal Business Name): PRASAD JOGU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2011
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL PLAZA DR
ROSEVILLE CA
95661-3037
US

IV. Provider business mailing address

10470 OLD PLACERVILLE RD STE 100
SACRAMENTO CA
95827-2539
US

V. Phone/Fax

Practice location:
  • Phone: 916-781-1927
  • Fax: 916-781-1787
Mailing address:
  • Phone: 800-972-5547
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number270736
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number270736
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberC153206
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberC153295
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: