Provider Demographics
NPI:1659394286
Name:PRUITT, CHRISTOPHER R (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:R
Last Name:PRUITT
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 1:2020 NORTH CENTRAL AVENUE
Mailing Address - Street 2:SUITE 1010
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004
Mailing Address - Country:US
Mailing Address - Phone:602-553-8400
Mailing Address - Fax:602-553-8408
Practice Address - Street 1:2020 NORTH CENTRAL AVENUE
Practice Address - Street 2:SUITE 1010
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004
Practice Address - Country:US
Practice Address - Phone:602-553-8400
Practice Address - Fax:602-553-8408
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ32867207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ92039913Medicaid
AZZ102812Medicare PIN
AZ92039913Medicaid