Provider Demographics
NPI:1114922697
Name:PRUKOP, BRYAN J (DPM)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:J
Last Name:PRUKOP
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:812 LINDBERG AVE
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78501-2930
Mailing Address - Country:US
Mailing Address - Phone:956-971-9107
Mailing Address - Fax:956-971-9109
Practice Address - Street 1:812 LINDBERG AVE
Practice Address - Street 2:
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78501-2930
Practice Address - Country:US
Practice Address - Phone:956-971-9107
Practice Address - Fax:956-971-9109
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1500213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX046355601Medicaid
TX046355601Medicaid
TX4661430001Medicare NSC
TX8812KOMedicare PIN
TXU81366Medicare UPIN
TX046355601Medicaid
TX157919501Medicaid