=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841523529
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PRABHUDEV PRASAD A PURUDAPPA MBBS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2009
-----------------------------------------------------
Last Update Date | 11/19/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 150 S HUNTINGTON AVE # 6C
-----------------------------------------------------
City | BOSTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02130-4817
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 857-364-4720
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 150 S HUNTINGTON AVE # 6C
-----------------------------------------------------
City | BOSTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02130-4817
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-574-6890
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | 1016126
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | L-240117
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207XS0114X
-----------------------------------------------------
Taxonomy Name | Adult Reconstructive Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | MD40483
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207XX0005X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Orthopaedic Surgery) Physician
-----------------------------------------------------
License Number | 105713
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------