Provider Demographics
NPI:1124024591
Name:PRUSNOFSKY, LESLIE (MD)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:
Last Name:PRUSNOFSKY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:361 ROUTE 202
Mailing Address - Street 2:
Mailing Address - City:SOMERS
Mailing Address - State:NY
Mailing Address - Zip Code:10589-3246
Mailing Address - Country:US
Mailing Address - Phone:914-631-6880
Mailing Address - Fax:914-631-2422
Practice Address - Street 1:361 ROUTE 202
Practice Address - Street 2:
Practice Address - City:SOMERS
Practice Address - State:NY
Practice Address - Zip Code:10589-3246
Practice Address - Country:US
Practice Address - Phone:914-631-6880
Practice Address - Fax:914-631-2422
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-21
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1352572084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYB15288Medicare UPIN
NY49A111Medicare ID - Type Unspecified