Healthcare Provider Details

I. General information

NPI: 1821353178
Provider Name (Legal Business Name): PRASANTH MOHAN NAVARASALA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2012
Last Update Date: 07/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 SAINT ANTOINE ST 6C
DETROIT MI
48201-2153
US

IV. Provider business mailing address

76 W ADAMS AVE APT. 402
DETROIT MI
48226-1617
US

V. Phone/Fax

Practice location:
  • Phone: 313-577-5310
  • Fax:
Mailing address:
  • Phone: 248-250-0733
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number4301101334
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: