Provider Demographics
NPI:1053454934
Name:PRABHAKAR, PUNAM (MD)
Entity type:Individual
Prefix:DR
First Name:PUNAM
Middle Name:
Last Name:PRABHAKAR
Suffix:
Gender:F
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 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-1290
Mailing Address - Fax:239-343-4008
Practice Address - Street 1:13782 PLANTATION RD STE 201
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4462
Practice Address - Country:US
Practice Address - Phone:239-343-1290
Practice Address - Fax:239-343-4008
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01083325A2084N0400X
FLME928442084N0400X
NY8762422084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL110868100Medicaid
FL013556700Medicaid