Healthcare Provider Details

I. General information

NPI: 1124024591
Provider Name (Legal Business Name): LESLIE PRUSNOFSKY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 01/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

361 ROUTE 202
SOMERS NY
10589-3246
US

IV. Provider business mailing address

361 ROUTE 202
SOMERS NY
10589-3246
US

V. Phone/Fax

Practice location:
  • Phone: 914-631-6880
  • Fax: 914-631-2422
Mailing address:
  • Phone: 914-631-6880
  • Fax: 914-631-2422

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number135257
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: