Provider Demographics
NPI:1720079775
Name:PRUSAKOWSKI, PAUL E (CPO, LPO)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:E
Last Name:PRUSAKOWSKI
Suffix:
Gender:M
Credentials:CPO, LPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6830 NW 11TH PL
Mailing Address - Street 2:STE A
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-4254
Mailing Address - Country:US
Mailing Address - Phone:352-331-4221
Mailing Address - Fax:352-332-8074
Practice Address - Street 1:6830 NW 11TH PL
Practice Address - Street 2:STE A
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605-4254
Practice Address - Country:US
Practice Address - Phone:352-331-4221
Practice Address - Fax:352-332-8074
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPOR56222Z00000X, 224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1234870001Medicare NSC