Provider Demographics
NPI:1811907603
Name:PRUTZMAN, CHERISH JOY (MD)
Entity type:Individual
Prefix:
First Name:CHERISH
Middle Name:JOY
Last Name:PRUTZMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 KYLE DR
Mailing Address - Street 2:
Mailing Address - City:CEDARVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45314-9580
Mailing Address - Country:US
Mailing Address - Phone:937-767-7291
Mailing Address - Fax:937-767-1302
Practice Address - Street 1:7073 CLYO RD
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-4816
Practice Address - Country:US
Practice Address - Phone:937-435-5857
Practice Address - Fax:937-912-4960
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN55140207R00000X
OH35.088432207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN887642100Medicaid
OH2680755Medicaid
MN110015396Medicare PIN
OHH371801Medicare PIN
L57291Medicare UPIN