Healthcare Provider Details

I. General information

NPI: 1124059555
Provider Name (Legal Business Name): PRABHAKAR TIPIRNENI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 02/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 SALT POND RD BUILDING H-2
WAKEFIELD RI
02879-4314
US

IV. Provider business mailing address

24 SALT POND RD BUILDING H2
WAKEFIELD RI
02879
US

V. Phone/Fax

Practice location:
  • Phone: 401-789-0227
  • Fax: 401-789-4882
Mailing address:
  • Phone: 401-789-0227
  • Fax: 401-789-4882

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberRI6624
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberRI6624
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: