Provider Demographics
NPI:1487141438
Name:PALVANNAN, PRASHANTH
Entity type:Individual
Prefix:
First Name:PRASHANTH
Middle Name:
Last Name:PALVANNAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 WILLOCKS CIR
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:NJ
Mailing Address - Zip Code:08873-7462
Mailing Address - Country:US
Mailing Address - Phone:908-499-3346
Mailing Address - Fax:
Practice Address - Street 1:1015 WALNUT ST STE 620
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107
Practice Address - Country:US
Practice Address - Phone:215-955-6864
Practice Address - Fax:215-955-2878
Is Sole Proprietor?:No
Enumeration Date:2018-04-16
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PAMT215213208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program