Healthcare Provider Details

I. General information

NPI: 1043700735
Provider Name (Legal Business Name): NITIN K PRABHAKAR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2018
Last Update Date: 10/13/2025
Certification Date: 10/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 NORTHLAKE DR
SAN JOSE CA
95117-1251
US

IV. Provider business mailing address

PO BOX 7410882
CHICAGO IL
60674-0882
US

V. Phone/Fax

Practice location:
  • Phone: 872-231-3162
  • Fax:
Mailing address:
  • Phone: 702-899-0595
  • Fax: 702-977-1496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number164044
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberA164044
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: