Provider Demographics
NPI:1750346029
Name:PUTPRUSH, JOSEPH (MD)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:PUTPRUSH
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 1476
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-0476
Mailing Address - Country:US
Mailing Address - Phone:570-714-5525
Mailing Address - Fax:570-714-5548
Practice Address - Street 1:575 N RIVER ST
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18764-0999
Practice Address - Country:US
Practice Address - Phone:570-829-8111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD019559E207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0009443270006Medicaid
PA163288N6TMedicare PIN
PAB40413Medicare UPIN