Provider Demographics
NPI:1194036624
Name:PRUETT, BENJAMIN JAMES (DO)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:JAMES
Last Name:PRUETT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7473 N INGRAM AVE STE 111
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-5856
Mailing Address - Country:US
Mailing Address - Phone:559-272-2934
Mailing Address - Fax:559-485-6994
Practice Address - Street 1:6191 N THESTA ST
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-5266
Practice Address - Country:US
Practice Address - Phone:559-436-4737
Practice Address - Fax:559-436-4738
Is Sole Proprietor?:No
Enumeration Date:2010-06-30
Last Update Date:2020-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010189152085R0202X
VA390200000X
CA20A148382085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program