Provider Demographics
NPI:1861473514
Name:PRUSTY, DEEPANWITA (MD PHD)
Entity Type:Individual
Prefix:MS
First Name:DEEPANWITA
Middle Name:
Last Name:PRUSTY
Suffix:
Gender:F
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 LONGWATER DR
Mailing Address - Street 2:
Mailing Address - City:NORWELL
Mailing Address - State:MA
Mailing Address - Zip Code:02061-1683
Mailing Address - Country:US
Mailing Address - Phone:781-878-5200
Mailing Address - Fax:781-681-9253
Practice Address - Street 1:541 MAIN ST 2ND
Practice Address - Street 2:
Practice Address - City:SOUTH WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02190-1868
Practice Address - Country:US
Practice Address - Phone:781-812-2880
Practice Address - Fax:781-803-6142
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA214928174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
042297845OtherTRICARE
1861473514OtherFALLON
MASS0074OtherBCBSMA
042297845OtherGREAT WEST
042297845OtherHCVM
042297845OtherUNITED HEALTH CARE
MA11078614AMedicaid
042297845OtherGIC UNICARE
MA1861473514OtherNEIGHBORHOOD HEALTH PLAN
9355125OtherAETNA
7541384OtherCIGNA
042297845OtherMULTI-PLAN
1861473514OtherNHP
459067OtherTUFTS AND TUFTS MEDICARE PREFERRED
AA193220OtherHARVARD PILGRIM
042297845OtherGIC UNICARE