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1164846986

NPI Code Detail

MEDICARE: DEREK PRABHARASUTH MD

MEDICARE: DEREK PRABHARASUTH 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	208800000X	Urology Physician	ME122730	FL
2	208800000X	Urology Physician	60 255424	NY
3	208800000X	Urology Physician	01099585A	IN
4	208800000X	Urology Physician	74307	GA

Other Identifiers

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

General Provider Information

NPI Number	:	1164846986
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEREK PRABHARASUTH MD

Provider Business Mailing Address
First Line	:	250 N SHADELAND AVE
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46219-4959
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5165 MCCARTY LN
Second Line	:
City	:	LAFAYETTE
State	:	IN
Zip	:	47905-8764
Country	:	US
Telephone Number	:	765-448-8000
Fax Number	:	765-838-4758

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

Provider Enumeration Date	:	02/13/2014
Last Update Date	:	05/08/2026

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Directions to “ DEREK PRABHARASUTH MD” Practice Location

Language	Start Address	Practice Location

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