Provider Demographics
NPI:1164153706
Name:PRUTCH, MELISSA N (DPM)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:N
Last Name:PRUTCH
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15815 SHADDOCK DR STE 130
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-5773
Mailing Address - Country:US
Mailing Address - Phone:813-400-1140
Mailing Address - Fax:813-701-9132
Practice Address - Street 1:1005 DALE MABRY HWY
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33548-3021
Practice Address - Country:US
Practice Address - Phone:813-549-5678
Practice Address - Fax:813-701-9132
Is Sole Proprietor?:No
Enumeration Date:2022-06-23
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO4507213ES0103X, 213E00000X, 213EP1101X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery