Provider Demographics
NPI:1942200894
Name:PRUSACZYK, HENRYK (MD)
Entity Type:Individual
Prefix:DR
First Name:HENRYK
Middle Name:
Last Name:PRUSACZYK
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:PO BOX 11716
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12211-0716
Mailing Address - Country:US
Mailing Address - Phone:518-783-0035
Mailing Address - Fax:518-786-1160
Practice Address - Street 1:1072 TROY SCHENECTADY RD
Practice Address - Street 2:NEW ENGLAND LASER AND COSMETIC SURGERY CENTER
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-1025
Practice Address - Country:US
Practice Address - Phone:518-783-0035
Practice Address - Fax:518-786-1160
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY194956207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
G02058Medicare UPIN