Provider Demographics
NPI:1164733812
Name:PRISHUTOVA, ANNA (MD)
Entity Type:Individual
Prefix:DR
First Name:ANNA
Middle Name:
Last Name:PRISHUTOVA
Suffix:
Gender:F
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:PO BOX 417
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34995-0417
Mailing Address - Country:US
Mailing Address - Phone:772-223-2832
Mailing Address - Fax:772-223-5646
Practice Address - Street 1:200 SE HOSPITAL AVE
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-2346
Practice Address - Country:US
Practice Address - Phone:772-223-5816
Practice Address - Fax:772-288-5834
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-28
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME119413207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL013446400Medicaid
FL14X4NOtherFLORIDA BLUE
FLHZ517Medicare PIN