Provider Demographics
NPI:1679575112
Name:PRUZAN, DEBRA L (MD)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:L
Last Name:PRUZAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1290 SUMMER ST
Mailing Address - Street 2:SUITE 3600
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06905-5360
Mailing Address - Country:US
Mailing Address - Phone:203-325-3576
Mailing Address - Fax:203-325-4280
Practice Address - Street 1:1290 SUMMER ST
Practice Address - Street 2:SUITE 3600
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-5360
Practice Address - Country:US
Practice Address - Phone:203-325-3576
Practice Address - Fax:203-325-4280
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT031601174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
070000406Medicare ID - Type Unspecified
E64956Medicare UPIN