Healthcare Provider Details

I. General information

NPI: 1639168784
Provider Name (Legal Business Name): PRASHANT BALWANT BAGALKOTKAR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2005
Last Update Date: 11/16/2022
Certification Date: 11/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

576 STERNBERG AVE
FORT EUSTIS VA
23604-1527
US

IV. Provider business mailing address

576 STERNBERG AVE
FORT EUSTIS VA
23604-1527
US

V. Phone/Fax

Practice location:
  • Phone: 757-314-7887
  • Fax:
Mailing address:
  • Phone: 757-314-7682
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101049685
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: