MEDICARE: PRABHJIT S. PUREWAL, MD, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332900000X	Non-Pharmacy Dispensing Site	A48423	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	5622368	OTHER	OTHER ID NUMBER-COMMERCIAL NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	5622368	OTHER	OTHER ID NUMBER

General Provider Information

NPI Number	:	1831206432
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRABHJIT S. PUREWAL, MD, INC.

Provider Business Mailing Address
First Line	:	PO BOX 7935
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95267-0935
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	200 COTTAGE AVE
Second Line	:	STE 201
City	:	MANTECA
State	:	CA
Zip	:	95336-4935
Country	:	US
Telephone Number	:	209-477-2000
Fax Number	:	209-477-0248

Authorized Official
Title or Position	:	CEO
Name	:	PRABHJIT PUREWAL
Credential	:
Telephone Number	:	209-477-2000

Provider Enumeration Date	:	08/23/2006
Last Update Date	:	06/22/2009

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