Provider Demographics
NPI:1831206432
Name:PRABHJIT S. PUREWAL, MD, INC.
Entity type:Organization
Organization Name:PRABHJIT S. PUREWAL, MD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PRABHJIT
Authorized Official - Middle Name:
Authorized Official - Last Name:PUREWAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-477-2000
Mailing Address - Street 1:PO BOX 7935
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95267-0935
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 COTTAGE AVE
Practice Address - Street 2:STE 201
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336-4935
Practice Address - Country:US
Practice Address - Phone:209-477-2000
Practice Address - Fax:209-477-0248
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2009-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA48423332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
5622368OtherOTHER ID NUMBER-COMMERCIAL NUMBER
CA00A48423Medicaid
5622368OtherOTHER ID NUMBER