Healthcare Provider Details

I. General information

NPI: 1841523529
Provider Name (Legal Business Name): PRABHUDEV PRASAD A PURUDAPPA MBBS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2009
Last Update Date: 11/19/2024
Certification Date: 11/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 S HUNTINGTON AVE # 6C
BOSTON MA
02130-4817
US

IV. Provider business mailing address

150 S HUNTINGTON AVE # 6C
BOSTON MA
02130-4817
US

V. Phone/Fax

Practice location:
  • Phone: 857-364-4720
  • Fax:
Mailing address:
  • Phone: 515-574-6890
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number1016126
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberL-240117
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License NumberMD40483
License Number StateIA
# 4
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number105713
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: