Provider Demographics
NPI:1750397782
Name:PRUITT, DAVID EDWIN (MD,)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:EDWIN
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:PO BOX 22148
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71903-2148
Mailing Address - Country:US
Mailing Address - Phone:501-622-1913
Mailing Address - Fax:501-622-4676
Practice Address - Street 1:1455 HIGDON FERRY RD
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71913-6419
Practice Address - Country:US
Practice Address - Phone:501-622-2100
Practice Address - Fax:501-622-2214
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE3086174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
7596359OtherAETNA ID #
AR5L933OtherBLUE CROSS PROV #
E14833Medicare UPIN
5L933Medicare ID - Type Unspecified