Provider Demographics
NPI:1497702096
Name:PRUITT, MELISSA D (MD)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:D
Last Name:PRUITT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:D
Other - Last Name:PRUITT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:404 W SCENIC DR
Mailing Address - Street 2:
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72118-5152
Mailing Address - Country:US
Mailing Address - Phone:901-412-7007
Mailing Address - Fax:
Practice Address - Street 1:3333 SPRINGHILL DR
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72117
Practice Address - Country:US
Practice Address - Phone:501-202-3802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-28
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-14973207Q00000X, 207P00000X
ARE14972207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR283254001Medicaid
MS02332770Medicaid
TN37332711Medicare PIN