Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QA0505X | Family Doctor - Adult Medicine | 026220 | NJ |
NPI | 1265508238 |
---|---|
Provider Name | Mallappa Nanjappa Prabhu |
First Address | Succasunna, NJ 07876-1055 |
Second Address | Greystone Park, NJ 07950 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/11/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
E13563 | (02) | NJ |