Provider Demographics
NPI:1821168436
Name:PRUETT, JILL ELIZABETH (MD)
Entity Type:Individual
Prefix:DR
First Name:JILL
Middle Name:ELIZABETH
Last Name:PRUETT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1015 NW 22ND AVENUE
Mailing Address - Street 2:R 200
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-3025
Mailing Address - Country:US
Mailing Address - Phone:503-413-8407
Mailing Address - Fax:503-413-7361
Practice Address - Street 1:1015 NW 22ND AVENUE
Practice Address - Street 2:R 200
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3025
Practice Address - Country:US
Practice Address - Phone:503-413-8407
Practice Address - Fax:503-413-7361
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2011-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD18835207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR150774Medicaid
G57254Medicare UPIN
OR150774Medicaid