Provider Demographics
NPI:1689825135
Name:PRABHU, SOMNATH JAGANNATH (MD)
Entity type:Individual
Prefix:DR
First Name:SOMNATH
Middle Name:JAGANNATH
Last Name:PRABHU
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 1418
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-1418
Mailing Address - Country:US
Mailing Address - Phone:805-286-3826
Mailing Address - Fax:805-221-6843
Practice Address - Street 1:938 NW KINGS BLVD
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-2505
Practice Address - Country:US
Practice Address - Phone:541-758-5047
Practice Address - Fax:541-758-3713
Is Sole Proprietor?:No
Enumeration Date:2008-10-02
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAML600269722085R0202X, 208600000X
WAMD604798442085R0202X
ORMD1996462085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2018572Medicaid
WAG8944879Medicare PIN
WA2018572Medicaid
WAG8944878Medicare PIN
WAG8944881Medicare PIN