=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477993152
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVID PRUTZMAN D.O.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/26/2013
-----------------------------------------------------
Last Update Date | 02/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18700 N 64TH DR STE 201
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85308-7112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-841-0741
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 ELLIOT WAY STE 100
-----------------------------------------------------
City | MANCHESTER
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03103-3502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-627-1669
-----------------------------------------------------
Fax | 603-624-2297
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RI0011X
-----------------------------------------------------
Taxonomy Name | Interventional Cardiology Physician
-----------------------------------------------------
License Number | 20748
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------