Healthcare Provider Details

I. General information

NPI: 1588769830
Provider Name (Legal Business Name): LEONARD GEORGE PRUTSOK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 W STEWART DR SUITE 214
ORANGE CA
92868-3854
US

IV. Provider business mailing address

1310 W STEWART DR SUITE 214
ORANGE CA
92868-3854
US

V. Phone/Fax

Practice location:
  • Phone: 714-997-9078
  • Fax: 714-997-9771
Mailing address:
  • Phone: 714-997-9078
  • Fax: 714-997-9771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG18825
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: