1821045147 NPI number — DR. JOHN W PRUITT D.D.S., M.D.

Table of content: DR. JOHN W PRUITT D.D.S., M.D. (NPI 1821045147)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821045147 NPI number — DR. JOHN W PRUITT D.D.S., M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PRUITT
Provider First Name:
JOHN
Provider Middle Name:
W
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.D.S., M.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:
1821045147
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/31/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10972 ALLISONVILLE RD
Provider Second Line Business Mailing Address:
SUITE 110
Provider Business Mailing Address City Name:
FISHERS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46038-2637
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-913-2363
Provider Business Mailing Address Fax Number:
317-913-2360

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1630 W SMITH VALLEY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENWOOD
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46142-1550
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-882-3370
Provider Business Practice Location Address Fax Number:
317-882-2964
Provider Enumeration Date:
05/30/2006

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: 1223S0112X , with the licence number:  12009797A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200078820 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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