=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700800661
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RAGHAVENDRA S PRASAD MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2006
-----------------------------------------------------
Last Update Date | 05/19/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 445 E FM 1382 #3354
-----------------------------------------------------
City | CEDAR HILL
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-325-1969
-----------------------------------------------------
Fax | 972-291-0019
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 445 E FM 1382 #3354
-----------------------------------------------------
City | CEDAR HILL
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-325-1969
-----------------------------------------------------
Fax | 972-291-0019
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QG0300X
-----------------------------------------------------
Taxonomy Name | Geriatric Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | J6213
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------