Provider Demographics
NPI:1194808253
Name:PRUITT, DON L (MD PROFCORP)
Entity type:Individual
Prefix:
First Name:DON
Middle Name:L
Last Name:PRUITT
Suffix:
Gender:M
Credentials:MD PROFCORP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 59
Mailing Address - Street 2:
Mailing Address - City:SUCHES
Mailing Address - State:GA
Mailing Address - Zip Code:30572-0059
Mailing Address - Country:US
Mailing Address - Phone:706-747-1421
Mailing Address - Fax:706-747-1423
Practice Address - Street 1:56 FIREWATER LN
Practice Address - Street 2:
Practice Address - City:SUCHES
Practice Address - State:GA
Practice Address - Zip Code:30572-2941
Practice Address - Country:US
Practice Address - Phone:706-747-1421
Practice Address - Fax:706-747-1423
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA019982208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000192255FMedicaid
GA000192255FMedicaid
GAD30520Medicare UPIN