Healthcare Provider Details

I. General information

NPI: 1073006375
Provider Name (Legal Business Name): GRZEGORZ SEBASTIAN PUCHALA DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2018
Last Update Date: 06/12/2025
Certification Date: 06/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7300 N FRESNO ST
FRESNO CA
93720-2941
US

IV. Provider business mailing address

6036 LAUGHING CREEK ST
LAS VEGAS NV
89148-5518
US

V. Phone/Fax

Practice location:
  • Phone: 559-448-4500
  • Fax:
Mailing address:
  • Phone: 702-466-5630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberTL6832
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number14038A
License Number StateWY
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberS9053
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number20A23057
License Number StateCA
# 5
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberS9053
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: