Healthcare Provider Details

I. General information

NPI: 1881623106
Provider Name (Legal Business Name): JOHN W PRUETT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 10/18/2021
Certification Date: 10/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1240 E 9TH ST
RENO NV
89512-2964
US

IV. Provider business mailing address

PO BOX 22040
GREEN BAY WI
54305-2040
US

V. Phone/Fax

Practice location:
  • Phone: 775-323-0478
  • Fax: 775-789-4437
Mailing address:
  • Phone: 920-445-7222
  • Fax: 920-445-7289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number16290
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number15727
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number16290
License Number StateNV
# 4
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number15727
License Number StateMS
# 5
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number1299-320
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: