Provider Demographics
NPI:1669468997
Name:PRISUTA, RICHARD A (DO)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:A
Last Name:PRISUTA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:570-271-6578
Practice Address - Street 1:4469 RED ROCK RD
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:PA
Practice Address - Zip Code:17814-7606
Practice Address - Country:US
Practice Address - Phone:570-925-6424
Practice Address - Fax:570-925-5852
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS006907L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA010046082OtherRAILROAD MEDICARE
PA01016701OtherCAPITAL BLUE CROSS
PA8340OtherGEISINGER HEALTH PLAN
PA001289227Medicaid
PA010046082OtherRAILROAD MEDICARE
PA669453Medicare ID - Type Unspecified