Provider Demographics
NPI:1164876371
Name:PRUITT, RACHEL (MD)
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:
Last Name:PRUITT
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 1:410 LAKEVILLE RD STE 204
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11042-1103
Mailing Address - Country:US
Mailing Address - Phone:650-759-0433
Mailing Address - Fax:
Practice Address - Street 1:410 LAKEVILLE RD STE 204
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-1103
Practice Address - Country:US
Practice Address - Phone:650-759-0433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-14
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY328719207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery