Healthcare Provider Details

I. General information

NPI: 1477527380
Provider Name (Legal Business Name): SUBBANNA JAYAPRAKASH, M.D., S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6015 DURAND AVE 500
RACINE WI
53406-5089
US

IV. Provider business mailing address

6015 DURAND AVE 500
RACINE WI
53406-5089
US

V. Phone/Fax

Practice location:
  • Phone: 262-598-1001
  • Fax:
Mailing address:
  • Phone: 262-598-1001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number27676
License Number StateWI

VIII. Authorized Official

Name: SUBBANNA JAYAPRAKASH
Title or Position: OWNER
Credential: M.D.
Phone: 262-598-1001