Basic Information
| Provider Information | |||||||||
| NPI: | 1861473514 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PRUSTY | ||||||||
| FirstName: | DEEPANWITA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 143 LONGWATER DR | ||||||||
| Address2: | |||||||||
| City: | NORWELL | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020611683 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7818785200 | ||||||||
| FaxNumber: | 7816819253 | ||||||||
| Practice Location | |||||||||
| Address1: | 541 MAIN ST 2ND | ||||||||
| Address2: | |||||||||
| City: | SOUTH WEYMOUTH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021901868 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7818122880 | ||||||||
| FaxNumber: | 7818036142 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2005 | ||||||||
| LastUpdateDate: | 02/16/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 214928 | MA | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 042297845 | 01 | TRICARE | OTHER | 1861473514 | 01 | FALLON | OTHER | SS0074 | 01 | MA | BCBSMA | OTHER | 042297845 | 01 | GREAT WEST | OTHER | 042297845 | 01 | HCVM | OTHER | 042297845 | 01 | UNITED HEALTH CARE | OTHER | 11078614A | 05 | MA | MEDICAID | 042297845 | 01 | GIC UNICARE | OTHER | 1861473514 | 01 | MA | NEIGHBORHOOD HEALTH PLAN | OTHER | 9355125 | 01 | AETNA | OTHER | 7541384 | 01 | CIGNA | OTHER | 042297845 | 01 | MULTI-PLAN | OTHER | 1861473514 | 01 | NHP | OTHER | 459067 | 01 | TUFTS AND TUFTS MEDICARE PREFERRED | OTHER | AA193220 | 01 | HARVARD PILGRIM | OTHER |