Provider Demographics
NPI:1700063708
Name:CHRISTOPHER J PRUSINSKI DO PA
Entity Type:Organization
Organization Name:CHRISTOPHER J PRUSINSKI DO PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:J
Authorized Official - Last Name:PRUSINSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:321-421-6566
Mailing Address - Street 1:1310 W EAU GALLIE BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-5300
Mailing Address - Country:US
Mailing Address - Phone:321-421-6566
Mailing Address - Fax:321-421-6572
Practice Address - Street 1:1310 W EAU GALLIE BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-5300
Practice Address - Country:US
Practice Address - Phone:321-421-6566
Practice Address - Fax:321-421-6572
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-22
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS00056402084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL80190Medicare PIN
FLE23549Medicare UPIN