Healthcare Provider Details

I. General information

NPI: 1700032182
Provider Name (Legal Business Name): KUSUM R PRABHAKAR MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2008
Last Update Date: 08/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1336 WYOMING BLVD NE SUITE F
ALBUQUERQUE NM
87112-5066
US

IV. Provider business mailing address

PO BOX 65605
ALBUQUERQUE NM
87193-5605
US

V. Phone/Fax

Practice location:
  • Phone: 505-275-2442
  • Fax: 505-275-2443
Mailing address:
  • Phone: 505-275-2442
  • Fax: 505-275-2443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number77234
License Number StateNM

VIII. Authorized Official

Name: DR. KUSUM R PRABHAKAR
Title or Position: PRESIDENT
Credential: M.D
Phone: 505-275-2442