Provider Demographics
NPI:1760599450
Name:PRUITT, ALEXANDER (MD)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
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 1:20 W 6TH ST
Mailing Address - Street 2:
Mailing Address - City:SPENCER
Mailing Address - State:IA
Mailing Address - Zip Code:51301-3901
Mailing Address - Country:US
Mailing Address - Phone:712-580-2022
Mailing Address - Fax:712-580-2024
Practice Address - Street 1:20 W 6TH ST
Practice Address - Street 2:
Practice Address - City:SPENCER
Practice Address - State:IA
Practice Address - Zip Code:51301-3901
Practice Address - Country:US
Practice Address - Phone:712-580-2022
Practice Address - Fax:712-580-2024
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA29040207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA36190OtherBLUE CROSS BLUE SHIELD
SD7712720Medicaid
NE1948OtherMIDLANDS CHOICE
204803800OtherUS DEPT OF LABOR
P00266324OtherRAILROAD MEDICARE
SD29770OtherSIOUX VALLEY HLTH PLNS
IA1091892Medicaid
SD7712720Medicaid
IAI11303Medicare PIN