Provider Demographics
NPI:1154585545
Name:DEVINENI R PRASAD MD PA
Entity type:Organization
Organization Name:DEVINENI R PRASAD MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEVINENI
Authorized Official - Middle Name:
Authorized Official - Last Name:PRASAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:609-567-0608
Mailing Address - Street 1:777 S WHITE HORSE PIKE
Mailing Address - Street 2:SUITE E
Mailing Address - City:HAMMONTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08037-2029
Mailing Address - Country:US
Mailing Address - Phone:609-567-0608
Mailing Address - Fax:609-567-1295
Practice Address - Street 1:777 S WHITE HORSE PIKE
Practice Address - Street 2:SUITE E1
Practice Address - City:HAMMONTON
Practice Address - State:NJ
Practice Address - Zip Code:08037-2029
Practice Address - Country:US
Practice Address - Phone:609-567-0608
Practice Address - Fax:609-567-1295
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-15
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03254600208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1047520OtherHORIZON NJ HORIZON
NJ2929201Medicaid