Provider Demographics
NPI:1154612380
Name:PRUETT, DONNA JACOBI (MD)
Entity type:Individual
Prefix:DR
First Name:DONNA
Middle Name:JACOBI
Last Name:PRUETT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:DONNA
Other - Middle Name:J
Other - Last Name:JACOBI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:8880 UNIVERSITY PKWY
Mailing Address - Street 2:SUITE A
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32514-4937
Mailing Address - Country:US
Mailing Address - Phone:850-494-5939
Mailing Address - Fax:850-494-5962
Practice Address - Street 1:9999 CHEMSTRAND RD
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514-2724
Practice Address - Country:US
Practice Address - Phone:850-479-4456
Practice Address - Fax:850-473-3986
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL43401207RG0300X
AL4484207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL067241600Medicaid
AL009914935Medicaid
AL009914935Medicaid
FLD53366Medicare UPIN
FL067241600Medicaid