Healthcare Provider Details

I. General information

NPI: 1700082633
Provider Name (Legal Business Name): PRABHAKER SARDESAI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 CRANBERRY ST SUITE 120
ERIE PA
16507-1067
US

IV. Provider business mailing address

410 CRANBERRY ST SUITE 120
ERIE PA
16507-1067
US

V. Phone/Fax

Practice location:
  • Phone: 814-480-8040
  • Fax:
Mailing address:
  • Phone: 814-480-8040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberMD014777E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: