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

General Provider Information

NPI Number	:	1649222118
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRABHJIT S. PUREWAL, MD, INC

Provider Business Mailing Address
First Line	:	PO BOX 1047
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95201-1047
Country	:	US
Telephone Number	:	209-477-2000
Fax Number	:

Provider Business Practice Location Address
First Line	:	200 COTTAGE AVE
Second Line	:	STE 201
City	:	MANTECA
State	:	CA
Zip	:	95336-4935
Country	:	US
Telephone Number	:	209-477-2000
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	PRABHJIT S PUREWAL
Credential	:	MD, FACP
Telephone Number	:	209-477-2000

Provider Enumeration Date	:	05/16/2006
Last Update Date	:	08/22/2020

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