Healthcare Provider Details

I. General information

NPI: 1255595435
Provider Name (Legal Business Name): PRAKASH SAMUEL EAPEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2008
Last Update Date: 06/30/2025
Certification Date: 06/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 W BEN WHITE BLVD STE 200B
AUSTIN TX
78704-7002
US

IV. Provider business mailing address

2423 WILLIAMS DR STE 107
GEORGETOWN TX
78628-3269
US

V. Phone/Fax

Practice location:
  • Phone: 877-800-5722
  • Fax: 512-326-1682
Mailing address:
  • Phone: 877-800-5722
  • Fax: 512-869-2940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number16252
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2011022927
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberP0722
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: