Healthcare Provider Details

I. General information

NPI: 1811994601
Provider Name (Legal Business Name): PRAKASH R NANCHERLA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 08/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 PALO ALTO RD SUITE 200
SAN ANTONIO TX
78211-3758
US

IV. Provider business mailing address

7142 SAN PEDRO AVE SUITE 120
SAN ANTONIO TX
78216-6254
US

V. Phone/Fax

Practice location:
  • Phone: 210-403-0765
  • Fax: 210-547-9270
Mailing address:
  • Phone: 210-661-5622
  • Fax: 210-395-4012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberG7697
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: