Healthcare Provider Details

I. General information

NPI: 1477757797
Provider Name (Legal Business Name): PRASAD SURENDRANATH DALVIE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2007
Last Update Date: 01/28/2021
Certification Date: 01/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 HIGHLAND AVE CSC - D4/336
MADISON WI
53792
US

IV. Provider business mailing address

600 HIGHLAND AVE D4/336
MADISON WI
53792
US

V. Phone/Fax

Practice location:
  • Phone: 608-265-5243
  • Fax:
Mailing address:
  • Phone: 608-265-5243
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberTRN9650
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number50740-020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: