Healthcare Provider Details

I. General information

NPI: 1548821887
Provider Name (Legal Business Name): LAXMINARAYAN PRABHAKAR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2019
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 HIGHLAND AVE STE 101
GLEN RIDGE NJ
07028-1522
US

IV. Provider business mailing address

123 HIGHLAND AVE STE 101
GLEN RIDGE NJ
07028-1522
US

V. Phone/Fax

Practice location:
  • Phone: 973-744-9125
  • Fax:
Mailing address:
  • Phone: 973-744-9125
  • Fax: 973-744-0280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number25MA11677400
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number25MA11677400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: