Healthcare Provider Details

I. General information

NPI: 1548410574
Provider Name (Legal Business Name): PRATHAP KUMAR SIMHADRI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2008
Last Update Date: 07/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 MEMORIAL MEDICAL PKWY STE 507
DAYTONA BEACH FL
32117-5168
US

IV. Provider business mailing address

301 MEMORIAL MEDICAL PKWY
DAYTONA BEACH FL
32117-5167
US

V. Phone/Fax

Practice location:
  • Phone: 386-672-8595
  • Fax: 386-677-4987
Mailing address:
  • Phone: 386-231-1091
  • Fax: 386-231-1092

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberME121973
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: