Provider Demographics
NPI:1649525684
Name:PRUETER, JAMES C (DO)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:C
Last Name:PRUETER
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 1:1222 PATTERSON AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45402-2682
Mailing Address - Country:US
Mailing Address - Phone:937-496-2620
Mailing Address - Fax:
Practice Address - Street 1:1222 S PATTERSON BLVD STE 400
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45402-2642
Practice Address - Country:US
Practice Address - Phone:937-496-2620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-16
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-011112207Y00000X, 207Y00000X
OHNONE207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0103972Medicaid