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General NPI Number Information
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NPI Number | 1912079294
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Entity Type | Individual
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Provider Name | PRAKASH P DEVASKAR MD
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Gender | Male
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Dates
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Enumeration Date | 11/14/2006
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Last Update Date | 03/07/2023
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Provider Practice Location Address
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Address Line | 700 RIVER DR
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City | FORT BRAGG
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State | CA
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Zip | 95437-5403
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Country | US
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Telephone | 707-961-4631
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Fax | 707-964-1192
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Provider Business Mailing Address
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Address Line | 700 RIVER DR
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City | FORT BRAGG
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State | CA
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Zip | 95437-5403
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Country | US
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Telephone | 707-961-4631
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Fax | 707-964-1192
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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 | CA00A350680
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License Number State | CA
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