Provider Demographics
NPI:1891352746
Name:PRUSKY GRINBERG, GARY (DO)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:
Last Name:PRUSKY GRINBERG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:GARY
Other - Middle Name:
Other - Last Name:PRUSKY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:3301 HART WAY
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30039-4688
Mailing Address - Country:US
Mailing Address - Phone:678-651-9425
Mailing Address - Fax:
Practice Address - Street 1:1446 HARPER ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-0012
Practice Address - Country:US
Practice Address - Phone:706-721-9442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-28
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10974208000000X
GA923042080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics