Provider Demographics
NPI:1518233790
Name:PRUENTE, RYAN THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:THOMAS
Last Name:PRUENTE
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 1:10790 RANCHO BERNARDO RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-5705
Mailing Address - Country:US
Mailing Address - Phone:858-554-2626
Mailing Address - Fax:
Practice Address - Street 1:10666 N TORREY PINES RD
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1027
Practice Address - Country:US
Practice Address - Phone:858-554-2626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-01
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD1870442085R0202X
CAC1823652085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500742059Medicaid
WA0389175OtherLNI-TRA KING COUNTY
WA2097738Medicaid
WA0389177OtherLNI-DINW
WA0389176OtherLNI-UAOM
OR500742059Medicaid