MEDICARE: PRABHJIT S. PUREWAL, MD, INC.

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	174400000X	Specialist	A48423	CA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	ZZZ23785Z	OTHER	CA	MEDICARE
5	A484230	OTHER	CA	MEDICARE ID -TYPE UNSPECIFIED
8	DA3789	OTHER	CA	RAILRODA MEDICARE
9	P00023054	OTHER	CA	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ZZZ06721Z	OTHER	CA	BLUE SHIELD
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	00A484231	OTHER	CA	MEDI CAL
6	ZZZ65255Y	OTHER	CA	BLUE SHIELD
7	ZZZ65256Y	OTHER	CA	BLUE SHIELD
10	ZZZ65257Y	OTHER	CA	BLUE SHIELD
11	ZZZ66761Z	OTHER	CA	BLUE SHIELD

General Provider Information

NPI Number	:	1548239338
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRABHJIT S. PUREWAL, MD, INC.

Provider Business Mailing Address
First Line	:	PO BOX 7935
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95267-0935
Country	:	US
Telephone Number	:	209-823-0000
Fax Number	:	209-824-1449

Provider Business Practice Location Address
First Line	:	165 ST. DOMINIC'S DR
Second Line	:	STE 120, 140
City	:	MANTECA
State	:	CA
Zip	:	95337-7802
Country	:	US
Telephone Number	:	209-823-0000
Fax Number	:	209-824-1449

Authorized Official
Title or Position	:	CEO
Name	:	DR. PRABHJIT S PUREWAL
Credential	:	MD
Telephone Number	:	209-823-0000

Provider Enumeration Date	:	03/15/2006
Last Update Date	:	04/14/2011

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