MEDICARE: DR. SUBBANNA JAYAPRAKASH M.D.

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	208100000X	Physical Medicine & Rehabilitation Physician	O27676	WI

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	:	1568450211
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUBBANNA JAYAPRAKASH M.D.

Provider Business Mailing Address
First Line	:	7401 LATIGO CIR
Second Line	:
City	:	FRANKSVILLE
State	:	WI
Zip	:	53126-9468
Country	:	US
Telephone Number	:	262-886-6252
Fax Number	:

Provider Business Practice Location Address
First Line	:	3811 SPRING ST
Second Line	:	SUITE 301
City	:	RACINE
State	:	WI
Zip	:	53405-1667
Country	:	US
Telephone Number	:	262-687-6262
Fax Number	:	262-687-6261

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

Provider Enumeration Date	:	10/07/2005
Last Update Date	:	07/08/2007

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