Provider Demographics
NPI:1740209998
Name:PRACKUP, GEORGE M (MD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:M
Last Name:PRACKUP
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 1:101 N PLAINS INDUSTRIAL RD
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-2360
Mailing Address - Country:US
Mailing Address - Phone:203-949-2700
Mailing Address - Fax:203-949-2712
Practice Address - Street 1:73 MARKET ST
Practice Address - Street 2:
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10710-7602
Practice Address - Country:US
Practice Address - Phone:914-682-6538
Practice Address - Fax:914-457-1583
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0355672085R0202X
NY231576-12085R0202X, 2085R0202X
DC213382085R0202X
FLME 1009172085R0202X
IN01064657A2085R0202X
IL036-0889452085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036088945Medicaid
WI34584200Medicaid
ILK49925Medicare PIN
WIP00148573Medicare PIN
WI0017-32390Medicare ID - Type Unspecified
WI34584200Medicaid