1245348242 NPI number — DR. CRAIG BERNARD PRUITT O.D.

Table of content: DR. CRAIG BERNARD PRUITT O.D. (NPI 1245348242)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245348242 NPI number — DR. CRAIG BERNARD PRUITT O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PRUITT
Provider First Name:
CRAIG
Provider Middle Name:
BERNARD
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245348242
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
246 SAINT MATTHEWS LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPARTANBURG
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29301-1323
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-574-0311
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
VISION PLUS 1955 E MAIN ST
Provider Second Line Business Practice Location Address:
1955 EAST MAIN ST. SUITE C.
Provider Business Practice Location Address City Name:
DUNCAN
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29334
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-433-9555
Provider Business Practice Location Address Fax Number:
864-433-9523
Provider Enumeration Date:
08/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  1064 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: DA9780 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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