Provider Demographics
NPI:1154308658
Name:PRUETT, PETER B (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:B
Last Name:PRUETT
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 1:2550 S PARKER RD
Mailing Address - Street 2:STE 206
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80014-1622
Mailing Address - Country:US
Mailing Address - Phone:303-306-7783
Mailing Address - Fax:303-306-7753
Practice Address - Street 1:2550 S PARKER RD
Practice Address - Street 2:STE 206
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80014-1622
Practice Address - Country:US
Practice Address - Phone:303-306-7783
Practice Address - Fax:303-306-7753
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO29651207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01296516Medicaid
840428757014OtherRMHD
DE82504OtherBCBS
COC803643Medicare PIN
DE82504OtherBCBS
E90275Medicare UPIN
COP00281652Medicare PIN