Provider Demographics
NPI:1477761203
Name:PRAKASH, SIDDHARTH (MD)
Entity type:Individual
Prefix:DR
First Name:SIDDHARTH
Middle Name:
Last Name:PRAKASH
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 1:222 E 68TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065-6001
Mailing Address - Country:US
Mailing Address - Phone:212-879-4488
Mailing Address - Fax:
Practice Address - Street 1:2025 RICHMOND AVE STE 1A
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-3915
Practice Address - Country:US
Practice Address - Phone:718-494-0800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2432502085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02920607Medicaid
NY02920607Medicaid
NYA100066910Medicare PIN