Provider Demographics
NPI:1053363861
Name:PRUSS, MARTIN WALTER (MD)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:WALTER
Last Name:PRUSS
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 1:3309 S 750 W
Mailing Address - Street 2:
Mailing Address - City:RUSSIAVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46979-9146
Mailing Address - Country:US
Mailing Address - Phone:765-883-2273
Mailing Address - Fax:765-883-5168
Practice Address - Street 1:3309 S 750 W
Practice Address - Street 2:
Practice Address - City:RUSSIAVILLE
Practice Address - State:IN
Practice Address - Zip Code:46979-9146
Practice Address - Country:US
Practice Address - Phone:765-883-2273
Practice Address - Fax:765-883-5168
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH12675207Q00000X
IN01073482A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000877337OtherANTHEM
IN201235770Medicaid
IN201235770Medicaid
IN000000877337OtherANTHEM