Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208000000X | Pediatrician | P20254 | MD |
Y | 2080P0210X | Pediatric Nephrologist | D67656 | MD |
NPI | 1295887750 |
---|---|
Provider Name | Dr. Cozumel Southern Pruette |
First Address | Baltimore, MD 21264-4316 |
Second Address | Baltimore, MD 21287-0011 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/01/2007 |
Last Update Date | 01/03/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
055174100 | (05) | MD |