Provider Demographics
NPI:1053419572
Name:PRASAD, SURESH (MD)
Entity type:Individual
Prefix:
First Name:SURESH
Middle Name:
Last Name:PRASAD
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:PO BOX 4147
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79760
Mailing Address - Country:US
Mailing Address - Phone:432-332-3400
Mailing Address - Fax:432-332-6500
Practice Address - Street 1:403 PITTSBURG AVE
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-5224
Practice Address - Country:US
Practice Address - Phone:432-332-3400
Practice Address - Fax:432-332-6500
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK8430207RS0012X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX100749403Medicaid
8B8104Medicare PIN
G97505Medicare UPIN