Healthcare Provider Details

I. General information

NPI: 1912201435
Provider Name (Legal Business Name): DAVE PRAKASH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/23/2010
Last Update Date: 12/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5526 LAKE SIDE DR
BOSSIER CITY LA
71111-5504
US

IV. Provider business mailing address

PO BOX 184
BARKSDALE AFB LA
71110-0184
US

V. Phone/Fax

Practice location:
  • Phone: 315-882-2278
  • Fax:
Mailing address:
  • Phone: 315-882-2278
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number234586
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: