Basic Information
| Provider Information | |||||||||
| NPI: | 1730205279 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHANNA | ||||||||
| FirstName: | PRABJOT | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 117 ELLENFIELD ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029054513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014446779 | ||||||||
| FaxNumber: | 4014446912 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 HOPPIN ST STE 202 | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 02903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014446551 | ||||||||
| FaxNumber: | 4014443611 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2007 | ||||||||
| LastUpdateDate: | 10/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207WX0120X | MD16313 | RI | N | 207W00000X | MD16313 | RI | Y | Allopathic & Osteopathic Physicians | Ophthalmology | 207W00000X | 223857-1 | NY | N | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | MD16313 | 01 | RI | LICENSE | OTHER | 02219170 | 05 | NY | MEDICAID |