Healthcare Provider Details

I. General information

NPI: 1679251383
Provider Name (Legal Business Name): PRAKASH POUDEL JAISHI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2023
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date: 02/16/2024
Reactivation Date: 12/24/2024

III. Provider practice location address

1200 CHILDRENS AVE STE 14601
OKLAHOMA CITY OK
73104-4637
US

IV. Provider business mailing address

1955 1ST AVE APT 301
NEW YORK NY
10029-6440
US

V. Phone/Fax

Practice location:
  • Phone: 405-271-8001
  • Fax: 405-271-5535
Mailing address:
  • Phone: 972-854-1502
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number47822
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: