Basic Information
| Provider Information | |||||||||
| NPI: | 1386626372 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VALLABHANATH | ||||||||
| FirstName: | PRASHANTH | ||||||||
| MiddleName: | NMI | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 22009 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972692009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035587372 | ||||||||
| FaxNumber: | 5033445140 | ||||||||
| Practice Location | |||||||||
| Address1: | 1955 NW NORTHRUP ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972091614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032272020 | ||||||||
| FaxNumber: | 5032220614 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2005 | ||||||||
| LastUpdateDate: | 02/20/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 02/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | MD22584 | OR | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207WX0200X | MD22584 | OR | Y |
ID Information
| ID | Type | State | Issuer | Description | 288426 | 05 | OR | MEDICAID |