Provider Demographics
NPI:1124059555
Name:TIPIRNENI, PRABHAKAR (MD)
Entity type:Individual
Prefix:
First Name:PRABHAKAR
Middle Name:
Last Name:TIPIRNENI
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 1:24 SALT POND RD
Mailing Address - Street 2:BUILDING H2
Mailing Address - City:WAKEFIELD
Mailing Address - State:RI
Mailing Address - Zip Code:02879
Mailing Address - Country:US
Mailing Address - Phone:401-789-0227
Mailing Address - Fax:401-789-4882
Practice Address - Street 1:24 SALT POND RD
Practice Address - Street 2:BUILDING H-2
Practice Address - City:WAKEFIELD
Practice Address - State:RI
Practice Address - Zip Code:02879-4314
Practice Address - Country:US
Practice Address - Phone:401-789-0227
Practice Address - Fax:401-789-4882
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRI6624174400000X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9002254Medicaid
RI9002254Medicaid
RI049002254Medicare PIN