Provider Demographics
NPI:1740290162
Name:PRUSHIK, KENNETH H (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:H
Last Name:PRUSHIK
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 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1994 WELLNESS BLVD STE 110
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28110-7768
Practice Address - Country:US
Practice Address - Phone:704-384-8460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2018-00935208000000X
NY228253-12080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0600898OtherGHI
NY556Y51OtherBLUE CROSS/ BLUE SHIELD
NY02461633Medicaid
NY3C3318OtherHEALTHNET
NYP2939540OtherOXFORD
NYP2939540OtherOXFORD
NY02461633Medicaid