Provider Demographics
NPI:1356399232
Name:PRUITT, GERALD T (DO)
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:T
Last Name:PRUITT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:802 W KING ST STE J
Mailing Address - Street 2:
Mailing Address - City:OWOSSO
Mailing Address - State:MI
Mailing Address - Zip Code:48867-2100
Mailing Address - Country:US
Mailing Address - Phone:989-729-4071
Mailing Address - Fax:989-729-4072
Practice Address - Street 1:802 W KING ST STE J
Practice Address - Street 2:
Practice Address - City:OWOSSO
Practice Address - State:MI
Practice Address - Zip Code:48867-2100
Practice Address - Country:US
Practice Address - Phone:989-729-4071
Practice Address - Fax:989-729-4072
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101015307207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1356399232Medicaid
ID807243700Medicaid
ID1303069Medicare ID - Type Unspecified