Healthcare Provider Details

I. General information

NPI: 1720079775
Provider Name (Legal Business Name): PAUL E. PRUSAKOWSKI CPO, LPO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 12/03/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6830 NW 11TH PL STE A
GAINESVILLE FL
32605-4254
US

IV. Provider business mailing address

6830 NW 11TH PL STE A
GAINESVILLE FL
32605-4254
US

V. Phone/Fax

Practice location:
  • Phone: 352-331-4221
  • Fax: 352-332-8074
Mailing address:
  • Phone: 352-331-4221
  • Fax: 352-332-8074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code222Z00000X
TaxonomyOrthotist
License NumberPOR56
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License NumberPOR56
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: