=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912906124
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KARANVIR PRAKASH MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2005
-----------------------------------------------------
Last Update Date | 12/05/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 325 CHARLES H DIMMOCK PKWY STE 100
-----------------------------------------------------
City | COLONIAL HEIGHTS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23834-2986
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-526-5888
-----------------------------------------------------
Fax | 804-526-5401
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 325 CHARLES H DIMMOCK PKWY STE 100
-----------------------------------------------------
City | COLONIAL HEIGHTS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23834-2986
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-526-5888
-----------------------------------------------------
Fax | 804-526-5401
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207XX0004X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Foot and Ankle Surgery Physician
-----------------------------------------------------
License Number | 0101045456
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------