Provider Demographics
NPI:1316950405
Name:PRUSHA, JAMES (RD)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:
Last Name:PRUSHA
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1525 W HOMER ST
Mailing Address - Street 2:# 101
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60642-1280
Mailing Address - Country:US
Mailing Address - Phone:773-443-8680
Mailing Address - Fax:773-292-1939
Practice Address - Street 1:1525 W HOMER ST
Practice Address - Street 2:# 101
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-1280
Practice Address - Country:US
Practice Address - Phone:773-443-8680
Practice Address - Fax:773-292-1939
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.003327133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL99454Medicare ID - Type UnspecifiedREGISTERED DIETITIAN