Healthcare Provider Details

I. General information

NPI: 1336190917
Provider Name (Legal Business Name): JOHN LEON PRUEITT JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3626 NE 45TH ST SUITE 300
SEATTLE WA
98105-5652
US

IV. Provider business mailing address

3626 NE 45TH ST SUITE 300
SEATTLE WA
98105-5652
US

V. Phone/Fax

Practice location:
  • Phone: 206-526-0581
  • Fax: 206-526-0219
Mailing address:
  • Phone: 206-526-0581
  • Fax: 206-526-0219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberMD00012562
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: