Provider Demographics
NPI:1790873479
Name:PRUCY, DAVID WALTER (OD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:WALTER
Last Name:PRUCY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:234 W US HIGHWAY 30
Mailing Address - Street 2:
Mailing Address - City:SCHERERVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46375-1854
Mailing Address - Country:US
Mailing Address - Phone:219-322-4348
Mailing Address - Fax:219-322-4794
Practice Address - Street 1:234 W US HIGHWAY 30
Practice Address - Street 2:
Practice Address - City:SCHERERVILLE
Practice Address - State:IN
Practice Address - Zip Code:46375-1854
Practice Address - Country:US
Practice Address - Phone:219-322-4348
Practice Address - Fax:219-322-4794
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18000199B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN148030AMedicare ID - Type Unspecified
IN17839Medicare UPIN