Healthcare Provider Details

I. General information

NPI: 1164611513
Provider Name (Legal Business Name): PAUL BENJAMIN PRUETT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2007
Last Update Date: 06/22/2020
Certification Date: 06/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4528 CHAPMAN HWY
KNOXVILLE TN
37920-4359
US

IV. Provider business mailing address

4528 CHAPMAN HWY
KNOXVILLE TN
37920-4359
US

V. Phone/Fax

Practice location:
  • Phone: 865-579-3920
  • Fax: 865-579-3963
Mailing address:
  • Phone: 865-579-3920
  • Fax: 865-579-3963

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number51282
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number060144
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code207WX0009X
TaxonomyGlaucoma Specialist (Ophthalmology) Physician
License Number51282
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: