Healthcare Provider Details

I. General information

NPI: 1497803860
Provider Name (Legal Business Name): JEFFERY RANDALL PRUITT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 06/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ONE S BRYANT AVE
EDMOND OK
73034-6309
US

IV. Provider business mailing address

1 S BRYANT AVE
EDMOND OK
73034-6309
US

V. Phone/Fax

Practice location:
  • Phone: 405-359-5370
  • Fax: 405-359-5357
Mailing address:
  • Phone: 405-359-5370
  • Fax: 405-359-5357

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number23454
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number23454
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: