Healthcare Provider Details

I. General information

NPI: 1780518142
Provider Name (Legal Business Name): PREETI PRABHU DO
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2026
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1750 CLUB DR
VALLEJO CA
94592-1105
US

IV. Provider business mailing address

PO BOX 6932
FOLSOM CA
95763-6932
US

V. Phone/Fax

Practice location:
  • Phone: 916-202-3014
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number15349882
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: