Healthcare Provider Details

I. General information

NPI: 1245818632
Provider Name (Legal Business Name): MADISON K PRUITT DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2021
Last Update Date: 08/04/2025
Certification Date: 08/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2195 HARRODSBURG RD STE 125
LEXINGTON KY
40504-3543
US

IV. Provider business mailing address

2195 HARRODSBURG ROAD STE. 125
LEXINGTON KY
40504-3504
US

V. Phone/Fax

Practice location:
  • Phone: 859-218-3064
  • Fax: 859-257-8696
Mailing address:
  • Phone:
  • Fax: 859-323-6661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number05815
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number05815
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: