Basic Information
| Provider Information | |||||||||
| NPI: | 1689825135 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PRABHU | ||||||||
| FirstName: | SOMNATH | ||||||||
| MiddleName: | JAGANNATH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1418 | ||||||||
| Address2: | |||||||||
| City: | CORVALLIS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973391418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8052863826 | ||||||||
| FaxNumber: | 8052216843 | ||||||||
| Practice Location | |||||||||
| Address1: | 938 NW KINGS BLVD | ||||||||
| Address2: | |||||||||
| City: | CORVALLIS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973302505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417585047 | ||||||||
| FaxNumber: | 5417583713 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2008 | ||||||||
| LastUpdateDate: | 01/18/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | ML60026972 | WA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | MD60479844 | WA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 208600000X | ML60026972 | WA | N | Allopathic & Osteopathic Physicians | Surgery | 2085R0202X | MD199646 | OR | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 2018572 | 05 | WA | MEDICAID |