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NPI Code Detail

MEDICARE: DR. JOHN W PRUETT M.D.

MEDICARE: DR. JOHN W PRUETT M.D.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
12084P0800XPsychiatry Physician16290NV
22084P0800XPsychiatry Physician15727MS
32084P0804XChild & Adolescent Psychiatry Physician16290NV
42084P0804XChild & Adolescent Psychiatry Physician15727MS
52084P0800XPsychiatry Physician1299-320WI

General Provider Information

NPI Number : 1881623106
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. JOHN W PRUETT M.D.
Provider Business Mailing Address
First Line : PO BOX 22040
Second Line :
City : GREEN BAY
State : WI
Zip : 54305-2040
Country : US
Telephone Number : 920-445-7222
Fax Number : 920-445-7289
Provider Business Practice Location Address
First Line : 1240 E 9TH ST
Second Line :
City : RENO
State : NV
Zip : 89512-2964
Country : US
Telephone Number : 775-323-0478
Fax Number : 775-789-4437
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/30/2006
Last Update Date : 10/18/2021

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