Healthcare Provider Details

I. General information

NPI: 1912906124
Provider Name (Legal Business Name): KARANVIR PRAKASH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 12/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 CHARLES H DIMMOCK PKWY STE 100
COLONIAL HEIGHTS VA
23834-2986
US

IV. Provider business mailing address

325 CHARLES H DIMMOCK PKWY STE 100
COLONIAL HEIGHTS VA
23834-2986
US

V. Phone/Fax

Practice location:
  • Phone: 804-526-5888
  • Fax: 804-526-5401
Mailing address:
  • Phone: 804-526-5888
  • Fax: 804-526-5401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License Number0101045456
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: