MEDICARE: DR. YARON PRUGININ PSY.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	PSY21146	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PSY21146	OTHER	CA	PSYCHOLOGIST

General Provider Information

NPI Number	:	1235206640
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. YARON PRUGININ PSY.D.

Provider Business Mailing Address
First Line	:	4565 RUFFNER ST STE 203
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92111-2259
Country	:	US
Telephone Number	:	619-838-4255
Fax Number	:

Provider Business Practice Location Address
First Line	:	4565 RUFFNER ST STE 108
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92111-2258
Country	:	US
Telephone Number	:	858-268-9000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/29/2006
Last Update Date	:	06/04/2010

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