Healthcare Provider Details

I. General information

NPI: 1740209998
Provider Name (Legal Business Name): GEORGE M PRACKUP M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 DIAMOND HILL RD
BERKELEY HEIGHTS NJ
07922-2104
US

IV. Provider business mailing address

263 FARMINGTON AVE
FARMINGTON CT
06030-8082
US

V. Phone/Fax

Practice location:
  • Phone: 908-277-8673
  • Fax: 908-790-6524
Mailing address:
  • Phone: 860-679-2784
  • Fax: 860-679-4126

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number035567
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number25MA12301500
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number60600
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number231576-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: