1861473514 NPI number — MS. DEEPANWITA PRUSTY MD PHD

Table of content: MS. DEEPANWITA PRUSTY MD PHD (NPI 1861473514)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861473514 NPI number — MS. DEEPANWITA PRUSTY MD PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PRUSTY
Provider First Name:
DEEPANWITA
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MD PHD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1861473514
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/16/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
143 LONGWATER DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORWELL
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02061-1683
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-878-5200
Provider Business Mailing Address Fax Number:
781-681-9253

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
541 MAIN ST 2ND
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH WEYMOUTH
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02190-1868
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-812-2880
Provider Business Practice Location Address Fax Number:
781-803-6142
Provider Enumeration Date:
11/09/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  214928 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 042297845 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1861473514 . This is a "FALLON" identifier . This identifiers is of the category "OTHER".
  • Identifier: SS0074 . This is a "BCBSMA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 042297845 . This is a "GREAT WEST" identifier . This identifiers is of the category "OTHER".
  • Identifier: 042297845 . This is a "HCVM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 042297845 . This is a "UNITED HEALTH CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 11078614A , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 042297845 . This is a "GIC UNICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1861473514 . This is a "NEIGHBORHOOD HEALTH PLAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 9355125 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7541384 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 042297845 . This is a "MULTI-PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1861473514 . This is a "NHP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 459067 . This is a "TUFTS AND TUFTS MEDICARE PREFERRED" identifier . This identifiers is of the category "OTHER".
  • Identifier: AA193220 . This is a "HARVARD PILGRIM" identifier . This identifiers is of the category "OTHER".