Provider Demographics
NPI:1578510780
Name:PRILLAMAN, PRESCOTT WADE (MD)
Entity type:Individual
Prefix:
First Name:PRESCOTT
Middle Name:WADE
Last Name:PRILLAMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7611 FOREST AVE
Mailing Address - Street 2:SUITE 330
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23229-4946
Mailing Address - Country:US
Mailing Address - Phone:804-673-8791
Mailing Address - Fax:804-673-3226
Practice Address - Street 1:7611 FOREST AVE
Practice Address - Street 2:SUITE 330
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23229-4946
Practice Address - Country:US
Practice Address - Phone:804-673-8791
Practice Address - Fax:804-673-3226
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101056025207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006201849Medicaid
160050950OtherMEDICARE RR
VA1578510780Medicaid
VA217097OtherANTHEM
VA1578510780Medicaid
P00752534Medicare PIN
160050950OtherMEDICARE RR
G63536Medicare UPIN