Healthcare Provider Details

I. General information

NPI: 1306947742
Provider Name (Legal Business Name): BILLY D PRUETT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 08/02/2023
Certification Date: 07/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15TH MDG 755 SCOTT CIRCLE
JBPH-HICKAM HI
96853
US

IV. Provider business mailing address

15TH MDG 755 SCOTT CIRCLE
JBPH-HICKAM HI
96853
US

V. Phone/Fax

Practice location:
  • Phone: 808-448-6371
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License NumberMD36551
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD36551
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License NumberMD36551
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: