Provider Demographics
NPI:1558455535
Name:PRUS-WISNIEWSKI, RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:PRUS-WISNIEWSKI
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 1:4 PRINCESS RD
Mailing Address - Street 2:SUITE #207
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08648-2322
Mailing Address - Country:US
Mailing Address - Phone:609-243-0445
Mailing Address - Fax:609-844-1092
Practice Address - Street 1:905 HERRONTOWN RD
Practice Address - Street 2:PRINCETON HOUSE BEHAVIORAL HEALTH
Practice Address - City:PRINCETON
Practice Address - State:NJ
Practice Address - Zip Code:08540-1901
Practice Address - Country:US
Practice Address - Phone:609-497-3300
Practice Address - Fax:609-497-3370
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MA68175002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8194602Medicaid
NJ036808Medicare ID - Type Unspecified
NJ8194602Medicaid