Provider Demographics
NPI:1649276437
Name:PISIPATI, PRABHAKAR (MD)
Entity type:Individual
Prefix:
First Name:PRABHAKAR
Middle Name:
Last Name:PISIPATI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:PRABHAKAR
Other - Middle Name:
Other - Last Name:PISIPATI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 862
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:IA
Mailing Address - Zip Code:52733-0862
Mailing Address - Country:US
Mailing Address - Phone:563-219-0695
Mailing Address - Fax:563-519-1444
Practice Address - Street 1:1075 JESSE JEWELL PKWY NE STE A
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3814
Practice Address - Country:US
Practice Address - Phone:770-219-5407
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-26
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010616882084P0805X
IA301432084P0805X
GA790022084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA79002OtherGA LICENSE
IA2115774Medicaid
074520030Medicare PIN
IAF72953Medicare UPIN