Provider Demographics
NPI:1700884848
Name:PRUITT, ANTHONY GENE (MD)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:GENE
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 1:2086 N 1700 W
Mailing Address - Street 2:SUITE C
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041
Mailing Address - Country:US
Mailing Address - Phone:801-773-8644
Mailing Address - Fax:801-927-1591
Practice Address - Street 1:5991 S 3500 W
Practice Address - Street 2:
Practice Address - City:ROY
Practice Address - State:UT
Practice Address - Zip Code:84067
Practice Address - Country:US
Practice Address - Phone:801-773-8644
Practice Address - Fax:801-985-0486
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5755419-1205208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT061506129008Medicaid