Healthcare Provider Details

I. General information

NPI: 1194762849
Provider Name (Legal Business Name): CHARLES PRUCHNO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 05/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 10TH ST SE
CEDAR RAPIDS IA
52403-2414
US

IV. Provider business mailing address

202 10TH ST SE
CEDAR RAPIDS IA
52403-2414
US

V. Phone/Fax

Practice location:
  • Phone: 319-247-3899
  • Fax:
Mailing address:
  • Phone: 319-247-3899
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD-27892
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number27892
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: