Healthcare Provider Details

I. General information

NPI: 1194036624
Provider Name (Legal Business Name): BENJAMIN JAMES PRUETT D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2010
Last Update Date: 05/05/2024
Certification Date: 05/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 E HERNDON AVE STE 110
FRESNO CA
93720-3333
US

IV. Provider business mailing address

1510 E HERNDON AVE STE 110
FRESNO CA
93720-3333
US

V. Phone/Fax

Practice location:
  • Phone: 559-436-4737
  • Fax: 559-436-4738
Mailing address:
  • Phone: 559-272-2934
  • Fax: 559-485-6994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number5101018915
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number20A14838
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: