Healthcare Provider Details

I. General information

NPI: 1609945427
Provider Name (Legal Business Name): PRASAD B PANTHAGANI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 03/21/2023
Certification Date: 03/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 COTTAGE GROVE RD SUITE B210
BLOOMFIELD CT
06002-3080
US

IV. Provider business mailing address

701 COTTAGE GROVE ROAD SUITE B210
BLOOMFIELD CT
06002
US

V. Phone/Fax

Practice location:
  • Phone: 860-242-9090
  • Fax: 860-242-9191
Mailing address:
  • Phone: 860-242-9191
  • Fax: 860-242-9090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number044859
License Number StateCT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier001448598
Identifier TypeMEDICAID
Identifier StateCT
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: