Healthcare Provider Details

I. General information

NPI: 1730295759
Provider Name (Legal Business Name): JOSEPH PRUSACZYK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13035 OLIVE BLVD
SAINT LOUIS MO
63141-6173
US

IV. Provider business mailing address

1623 TIMBERLAKE MANOR PKWY
CHESTERFIELD MO
63017-5593
US

V. Phone/Fax

Practice location:
  • Phone: 314-434-3114
  • Fax: 314-434-3117
Mailing address:
  • Phone: 314-434-3114
  • Fax: 314-434-3117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number31728
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: