Basic Information
| Provider Information | |||||||||
| NPI: | 1871527028 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEVABHAKTUNI | ||||||||
| FirstName: | PRASAD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3560 DELAWARE ST STE 209 | ||||||||
| Address2: | |||||||||
| City: | BEAUMONT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 777063059 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4098993682 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3560 DELAWARE ST STE 209 | ||||||||
| Address2: | |||||||||
| City: | BEAUMONT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 777063059 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4098993682 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 06/20/2012 | ||||||||
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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 | 2085R0202X | 036060837 | IL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0360608371 | 05 | IL | MEDICAID | 200462402 | 05 | TX | MEDICAID | 200108170 | 05 | IN | MEDICAID |