Provider Demographics
NPI:1548291461
Name:PRUNTY, MARSHALL EDWARD (MD)
Entity type:Individual
Prefix:
First Name:MARSHALL
Middle Name:EDWARD
Last Name:PRUNTY
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:PO BOX 23229
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42304-3229
Mailing Address - Country:US
Mailing Address - Phone:270-688-1330
Mailing Address - Fax:270-688-1338
Practice Address - Street 1:811 E PARRISH AVE STE 102
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-3258
Practice Address - Country:US
Practice Address - Phone:270-688-2077
Practice Address - Fax:270-688-2078
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY22988207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64229883Medicaid
IN201282610Medicaid
IN201282610Medicaid
KY64229883Medicaid
KYK080980Medicare PIN
KY64229883Medicaid
P400037195Medicare PIN