Provider Demographics
NPI:1427099654
Name:MATURU, PRASAD S (MD)
Entity type:Individual
Prefix:
First Name:PRASAD
Middle Name:S
Last Name:MATURU
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:# L-3652
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43260-6453
Mailing Address - Country:US
Mailing Address - Phone:740-383-7927
Mailing Address - Fax:740-383-7942
Practice Address - Street 1:1040 DELAWARE AVENUE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43301-1814
Practice Address - Country:US
Practice Address - Phone:740-383-7920
Practice Address - Fax:740-383-7942
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2015-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35053451M207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
643272OtherAETNA
OH0633470Medicaid
311098079037OtherCIGNA
100004717OtherTRAVELERS MEDICARE
2900073OtherUHC
311098079OtherPPO NEXT
OH000000118385OtherANTHEM
2900073OtherUHC
100004717OtherTRAVELERS MEDICARE
E29684Medicare UPIN