Basic Information
| Provider Information | |||||||||
| NPI: | 1609831197 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PROKHOROVA | ||||||||
| FirstName: | NATALYA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1040 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011032107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137391100 | ||||||||
| FaxNumber: | 4137351133 | ||||||||
| Practice Location | |||||||||
| Address1: | 1040 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011032107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137391100 | ||||||||
| FaxNumber: | 4137351133 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2006 | ||||||||
| LastUpdateDate: | 03/04/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 223850 | MA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 000000031647 | 01 | MA | HEALTHNET | OTHER | AA36432 | 01 | MA | HARVARD PILGRIM | OTHER | 1310097 | 05 | MA | MEDICAID | 967563 | 01 | MA | NETWORK HEALTH | OTHER | J28812 | 01 | MA | BC/BS | OTHER | BP9090262 | 01 | MA | DEA | OTHER | MP0591087A | 01 | MA | CSR | OTHER | 2235976 | 01 | MA | CIGNA | OTHER | 0036480 | 01 | MA | NHP | OTHER | 223850 | 01 | CONNECTICARE | OTHER | 36842 | 01 | MA | HNE | OTHER |