Healthcare Provider Details

I. General information

NPI: 1073615324
Provider Name (Legal Business Name): PRASHANT KAUSHIK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2006
Last Update Date: 12/15/2021
Certification Date: 12/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1373 E BOONE ST STE 2300
TAHLEQUAH OK
74464-3365
US

IV. Provider business mailing address

1373 E BOONE ST STE 2300
TAHLEQUAH OK
74464-3365
US

V. Phone/Fax

Practice location:
  • Phone: 918-207-0025
  • Fax: 918-207-0026
Mailing address:
  • Phone: 918-207-0025
  • Fax: 918-207-0026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number10324
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number277958
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number36301
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier10324
Identifier TypeOTHER
Identifier StateND
Identifier IssuerLICENSE
# 2
Identifier14044
Identifier TypeMEDICAID
Identifier StateND
Identifier Issuer
# 3
IdentifierP00341234
Identifier TypeOTHER
Identifier StateND
Identifier IssuerRAILROAD MEDICARE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: