Healthcare Provider Details

I. General information

NPI: 1598429482
Provider Name (Legal Business Name): CALEB LAWRENCE PRUITT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2021
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1008 N MAIN ST
SIKESTON MO
63801-5044
US

IV. Provider business mailing address

614 THORNWOOD AVE
SIKESTON MO
63801-4687
US

V. Phone/Fax

Practice location:
  • Phone: 573-380-2407
  • Fax:
Mailing address:
  • Phone: 573-380-2407
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number2018027462
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: