Provider Demographics
NPI:1649222118
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:
Authorized Official - First Name:PRABHJIT
Authorized Official - Middle Name:S
Authorized Official - Last Name:PUREWAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD, FACP
Authorized Official - Phone:209-477-2000
Mailing Address - Street 1:PO BOX 1047
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95201-1047
Mailing Address - Country:US
Mailing Address - Phone:209-477-2000
Mailing Address - Fax:
Practice Address - Street 1:200 COTTAGE AVE
Practice Address - Street 2:STE 201
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336-4935
Practice Address - Country:US
Practice Address - Phone:209-477-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2020-08-22
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
CAZZZ06721ZMedicare ID - Type Unspecified