Provider Demographics
NPI:1871527028
Name:DEVABHAKTUNI, PRASAD (MD)
Entity type:Individual
Prefix:
First Name:PRASAD
Middle Name:
Last Name:DEVABHAKTUNI
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 1:3560 DELAWARE ST STE 209
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77706-3059
Mailing Address - Country:US
Mailing Address - Phone:409-899-3682
Mailing Address - Fax:
Practice Address - Street 1:3560 DELAWARE ST STE 209
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77706-3059
Practice Address - Country:US
Practice Address - Phone:409-899-3682
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360608372085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360608371Medicaid
TX200462402Medicaid
IN200108170Medicaid
TX8L21575Medicare PIN
IN200108170Medicaid