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General NPI Number Information
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NPI Number | 1831514900
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Entity Type | Individual
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Provider Name | PRADEEP BANGALORE PRAKASH MD
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Gender | Male
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Dates
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Enumeration Date | 02/26/2014
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Last Update Date | 12/27/2024
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Provider Practice Location Address
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Address Line | 835 S VAN BUREN ST
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City | GREEN BAY
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State | WI
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Zip | 54301-3526
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Country | US
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Telephone | 920-496-4700
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Fax |
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Provider Business Mailing Address
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Address Line | 835 S VAN BUREN ST
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City | GREEN BAY
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State | WI
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Zip | 54301-3526
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Country | US
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Telephone | 920-496-4700
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | MD-41570
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License Number State | IA
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Taxonomy #2
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Taxonomy Code | 2080P0203X
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Taxonomy Name | Pediatric Critical Care Medicine Physician
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License Number | MD-41570
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License Number State | IA
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Taxonomy #3
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Taxonomy Code | 2080P0203X
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Taxonomy Name | Pediatric Critical Care Medicine Physician
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License Number | 72580-20
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License Number State | WI
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