Healthcare Provider Details

I. General information

NPI: 1700800661
Provider Name (Legal Business Name): RAGHAVENDRA S PRASAD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 05/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 E FM 1382 #3354
CEDAR HILL TX
75104
US

IV. Provider business mailing address

445 E FM 1382 #3354
CEDAR HILL TX
75104
US

V. Phone/Fax

Practice location:
  • Phone: 214-325-1969
  • Fax: 972-291-0019
Mailing address:
  • Phone: 214-325-1969
  • Fax: 972-291-0019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberJ6213
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: