Healthcare Provider Details

I. General information

NPI: 1396956165
Provider Name (Legal Business Name): DAVID E. PRUETT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 06/03/2024
Certification Date: 06/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 THOMAS RD STE 1
WEST MONROE LA
71292-7903
US

IV. Provider business mailing address

401 THOMAS RD STE 1
WEST MONROE LA
71292-7903
US

V. Phone/Fax

Practice location:
  • Phone: 318-325-5435
  • Fax: 318-325-5495
Mailing address:
  • Phone: 318-325-5435
  • Fax: 318-325-5495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberT-1940
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberMD.204452
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number20439
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: