1194808253 NPI number — DON L PRUITT M.D. PROF.CORP.

Table of content: DON L PRUITT M.D. PROF.CORP. (NPI 1194808253)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194808253 NPI number — DON L PRUITT M.D. PROF.CORP.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PRUITT
Provider First Name:
DON
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D. PROF.CORP.
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:
1194808253
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/30/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 59
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUCHES
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30572-0059
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-747-1421
Provider Business Mailing Address Fax Number:
706-747-1423

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
56 FIREWATER LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUCHES
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30572-2941
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-747-1421
Provider Business Practice Location Address Fax Number:
706-747-1423
Provider Enumeration Date:
10/23/2006

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: 208D00000X , with the licence number:  019982 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000192255F , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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