Healthcare Provider Details

I. General information

NPI: 1275108953
Provider Name (Legal Business Name): PRANAV PRAKASH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2021
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date: 11/14/2022
Reactivation Date: 02/07/2023

III. Provider practice location address

1077 GATEWAY LOOP
SPRINGFIELD OR
97477-1114
US

IV. Provider business mailing address

1077 GATEWAY LOOP
SPRINGFIELD OR
97477-1114
US

V. Phone/Fax

Practice location:
  • Phone: 541-485-6478
  • Fax: 541-868-9606
Mailing address:
  • Phone: 541-485-6478
  • Fax: 541-868-9606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberTRN33916
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberMD229125
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: