Basic Information
| Provider Information | |||||||||
| NPI: | 1467496760 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VAIDYA | ||||||||
| FirstName: | PRABHAKAR | ||||||||
| MiddleName: | NARHARI | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 14006 | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276204006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192313966 | ||||||||
| FaxNumber: | 9192313912 | ||||||||
| Practice Location | |||||||||
| Address1: | 3031 NEW BERN AVE | ||||||||
| Address2: | SUITE 306 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276101214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192313966 | ||||||||
| FaxNumber: | 9192313912 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 10/29/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 20214 | NC | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 390001311 | 01 | NC | PALMETTO GBA | OTHER | 84620 | 01 | NC | BLUE CROSS BLUE SHIELD | OTHER | 8984620 | 05 | NC | MEDICAID |