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1033104674

NPI Code Detail

MEDICARE: RENU B PRAKASH MD

MEDICARE: RENU B PRAKASH MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	159456	MA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	S400105529	OTHER	MA	MEDICARE - GROUP #003473101
2	S400105532	OTHER	MA	MEDICARE - GROUP #0034731

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1033104674
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RENU B PRAKASH MD

Provider Business Mailing Address
First Line	:	960 MASSACHUSETTS AVE STE 2
Second Line	:
City	:	BOSTON
State	:	MA
Zip	:	02118-2690
Country	:	US
Telephone Number	:	617-414-4505
Fax Number	:

Provider Business Practice Location Address
First Line	:	235 N PEARL ST
Second Line	:
City	:	BROCKTON
State	:	MA
Zip	:	02301-1794
Country	:	US
Telephone Number	:	617-789-3000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/20/2005
Last Update Date	:	03/17/2025

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Directions to “ RENU B PRAKASH MD” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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