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General NPI Number Information
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NPI Number | 1164810503
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Entity Type | Organization
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Legal Business Name | RADHIKA PRAKASH, MD
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Dates
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Enumeration Date | 01/08/2015
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Last Update Date | 01/08/2015
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Provider Practice Location Address
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Address Line | 2758 US S 1 SOUTH
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City | ST. AUGUSTINE
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State | FL
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Zip | 32086
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Country | US
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Telephone | 904-797-2338
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Fax | 904-797-2331
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Provider Business Mailing Address
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Address Line | PO BOX 860120
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City | ST AUGUSTINE
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State | FL
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Zip | 32086-0120
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Country | US
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Telephone | 904-797-2338
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Fax | 904-797-2331
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Authorized Official
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Title or Position | MD
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Name | RADHIKA PRAKASH
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Credential |
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Telephone | 904-797-2338
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | ME0041524
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License Number State | FL
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