Provider Demographics
NPI:1477527554
Name:PRUITT, JOHN CRAYTON JR (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:CRAYTON
Last Name:PRUITT
Suffix:JR
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 1:4902 EISENHOWER BLVD.
Mailing Address - Street 2:SUITE 300
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33634-6344
Mailing Address - Country:US
Mailing Address - Phone:813-636-2000
Mailing Address - Fax:813-321-6581
Practice Address - Street 1:3003 W. DR. MARTIN LUTHER KING JR. BLVD.
Practice Address - Street 2:MAB, 2ND FLOOR
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6307
Practice Address - Country:US
Practice Address - Phone:813-321-6580
Practice Address - Fax:813-321-6581
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME51980208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL048126200Medicaid
FL05769XMedicare PIN
FLD84900Medicare UPIN
FL048126200Medicaid
FL05769ZMedicare PIN