Provider Demographics
NPI:1659366284
Name:PRUITT, DONALD L (MD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:L
Last Name:PRUITT
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Gender:M
Credentials:MD
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Mailing Address - Street 1:12813 FLUSHING MEADOWS DRIVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131
Mailing Address - Country:US
Mailing Address - Phone:314-966-0111
Mailing Address - Fax:314-966-1023
Practice Address - Street 1:12855 NORTH FORTY DRIVE
Practice Address - Street 2:SUITE 125
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141
Practice Address - Country:US
Practice Address - Phone:314-966-0111
Practice Address - Fax:314-966-1023
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2011-10-21
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Provider Licenses
StateLicense IDTaxonomies
MOR5H33207X00000X, 207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
A27754Medicare UPIN