Healthcare Provider Details

I. General information

NPI: 1659402873
Provider Name (Legal Business Name): TIMOTHY L. PRUETT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 FULTON ST SE
MINNEAPOLIS MN
55455-4800
US

IV. Provider business mailing address

720 WASHINGTON AVE SE UNIVERSITY OF MINNESOTA PHYSICIANS
MINNEAPOLIS MN
55414
US

V. Phone/Fax

Practice location:
  • Phone: 612-672-7422
  • Fax:
Mailing address:
  • Phone: 612-884-0649
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License Number0101040520
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: