Healthcare Provider Details

I. General information

NPI: 1225083454
Provider Name (Legal Business Name): PRASAD V PODILA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 06/14/2022
Certification Date: 06/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4381 E LOHMAN AVE STE B
LAS CRUCES NM
88011-8255
US

IV. Provider business mailing address

4381 E LOHMAN AVE STE B
LAS CRUCES NM
88011-8255
US

V. Phone/Fax

Practice location:
  • Phone: 575-522-7697
  • Fax:
Mailing address:
  • Phone: 575-522-7697
  • Fax: 575-522-4840

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number98-136
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: