Provider Demographics
NPI:1588769830
Name:PRUTSOK, LEONARD GEORGE (MD)
Entity type:Individual
Prefix:DR
First Name:LEONARD
Middle Name:GEORGE
Last Name:PRUTSOK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 W STEWART DR
Mailing Address - Street 2:SUITE 214
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-3854
Mailing Address - Country:US
Mailing Address - Phone:714-997-9078
Mailing Address - Fax:714-997-9771
Practice Address - Street 1:1310 W STEWART DR
Practice Address - Street 2:SUITE 214
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3854
Practice Address - Country:US
Practice Address - Phone:714-997-9078
Practice Address - Fax:714-997-9771
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG18825174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA90563Medicare UPIN