Provider Demographics
NPI:1689012080
Name:PRUETT, DAWN MARIE (MD)
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:MARIE
Last Name:PRUETT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DAWN
Other - Middle Name:MARIE
Other - Last Name:POTHIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-721-8829
Mailing Address - Fax:
Practice Address - Street 1:4782 OXFORD DR
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-4253
Practice Address - Country:US
Practice Address - Phone:860-367-7267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-06
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY282231207Q00000X
NY283231207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04448371Medicaid