=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578627402
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOSEPH GARY PRUZINSKY OD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/22/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 103 CHANEY DRIVE
-----------------------------------------------------
City | OLYPHANT
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18447-1908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-489-4788
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 103 CHANEY DRIVE
-----------------------------------------------------
City | OLYPHANT
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18447-1908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-489-4788
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OE007359T
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------