Provider Demographics
NPI:1275694028
Name:PRUSS, MARIO EDUARDO (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:EDUARDO
Last Name:PRUSS
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 1:9650 SANTIAGO RD
Mailing Address - Street 2:SUITE 11
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-3957
Mailing Address - Country:US
Mailing Address - Phone:410-730-2385
Mailing Address - Fax:
Practice Address - Street 1:9650 SANTIAGO RD
Practice Address - Street 2:SUITE 11
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-3957
Practice Address - Country:US
Practice Address - Phone:410-730-2385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0045248251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDB46448Medicare UPIN