Provider Demographics
NPI:1205852985
Name:PRUTHI, JATINDER S (MD)
Entity Type:Individual
Prefix:DR
First Name:JATINDER
Middle Name:S
Last Name:PRUTHI
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:PO BOX 5988
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93539-5988
Mailing Address - Country:US
Mailing Address - Phone:661-948-0803
Mailing Address - Fax:661-948-5004
Practice Address - Street 1:1753-B W AVENUE J
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534
Practice Address - Country:US
Practice Address - Phone:661-948-0803
Practice Address - Fax:661-948-5004
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA64919207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A649190Medicaid
CAA47861Medicare ID - Type UnspecifiedMEDICARE