Provider Demographics
NPI:1124131867
Name:PRASAD, C M (MD)
Entity type:Individual
Prefix:DR
First Name:C
Middle Name:M
Last Name:PRASAD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:CHANNAVAJJALA
Other - Middle Name:M
Other - Last Name:PRASAD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD,PHD
Mailing Address - Street 1:PO BOX 604
Mailing Address - Street 2:
Mailing Address - City:MCLEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101-0604
Mailing Address - Country:US
Mailing Address - Phone:703-750-2013
Mailing Address - Fax:703-750-2014
Practice Address - Street 1:8221 WILLOW OAKS CORPORATE DR
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4512
Practice Address - Country:US
Practice Address - Phone:703-383-8500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010417202084P0800X
MDD 361982084P0800X
DC169492084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA081432OtherBCBS
VA7134673Medicaid
VAE 35125Medicare UPIN
VA081432OtherBCBS