=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548239338
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRABHJIT S. PUREWAL, MD, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2006
-----------------------------------------------------
Last Update Date | 04/14/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 165 ST. DOMINIC'S DR STE 120, 140
-----------------------------------------------------
City | MANTECA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95337-7802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-823-0000
-----------------------------------------------------
Fax | 209-824-1449
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 7935
-----------------------------------------------------
City | STOCKTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95267-0935
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-823-0000
-----------------------------------------------------
Fax | 209-824-1449
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. PRABHJIT S PUREWAL
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 209-823-0000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | A48423
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------