Provider Demographics
NPI:1295887750
Name:PRUETTE, COZUMEL SOUTHERN (MD, MHS)
Entity type:Individual
Prefix:DR
First Name:COZUMEL
Middle Name:SOUTHERN
Last Name:PRUETTE
Suffix:
Gender:F
Credentials:MD, MHS
Other - Prefix:DR
Other - First Name:COZUMEL
Other - Middle Name:ALLYSON
Other - Last Name:SOUTHERN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 64316
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4316
Mailing Address - Country:US
Mailing Address - Phone:410-955-4427
Mailing Address - Fax:
Practice Address - Street 1:200 N WOLFE ST
Practice Address - Street 2:ROOM 3055
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287-0011
Practice Address - Country:US
Practice Address - Phone:410-955-2467
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2013-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDP20254208000000X
MDD676562080P0210X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0210XAllopathic & Osteopathic PhysiciansPediatricsPediatric Nephrology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD055174100Medicaid
MD055174100Medicaid