Provider Demographics
NPI:1487742755
Name:SUDHEENDRAN, PRABHA (MD)
Entity type:Individual
Prefix:MRS
First Name:PRABHA
Middle Name:
Last Name:SUDHEENDRAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:PRABHAVATHY
Other - Middle Name:
Other - Last Name:SUDHEENDRAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:360 E EH CRUMP BLVD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38126-5310
Mailing Address - Country:US
Mailing Address - Phone:901-261-2000
Mailing Address - Fax:901-946-9262
Practice Address - Street 1:4299 ELVIS PRESLEY BLVD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38116
Practice Address - Country:US
Practice Address - Phone:901-398-7518
Practice Address - Fax:901-398-3128
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN013382208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3189854Medicaid
TN3189854Medicaid