Provider Demographics
NPI:1548239338
Name:PRABHJIT S. PUREWAL, MD, INC.
Entity Type:Organization
Organization Name:PRABHJIT S. PUREWAL, MD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:PRABHJIT
Authorized Official - Middle Name:S
Authorized Official - Last Name:PUREWAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-823-0000
Mailing Address - Street 1:PO BOX 7935
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95267-0935
Mailing Address - Country:US
Mailing Address - Phone:209-823-0000
Mailing Address - Fax:209-824-1449
Practice Address - Street 1:165 ST. DOMINIC'S DR
Practice Address - Street 2:STE 120, 140
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95337-7802
Practice Address - Country:US
Practice Address - Phone:209-823-0000
Practice Address - Fax:209-824-1449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-15
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA48423174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ06721ZOtherBLUE SHIELD
CAZZZ23785ZOtherMEDICARE
CA00A484230Medicaid
CA00A484231OtherMEDI CAL
CAA484230OtherMEDICARE ID -TYPE UNSPECIFIED
CAZZZ65255YOtherBLUE SHIELD
CAZZZ65256YOtherBLUE SHIELD
CADA3789OtherRAILRODA MEDICARE
CAP00023054OtherRAILROAD MEDICARE
CAZZZ65257YOtherBLUE SHIELD
CAZZZ66761ZOtherBLUE SHIELD
CAZZZ23785ZOtherMEDICARE
CADA3789OtherRAILRODA MEDICARE