Provider Demographics
NPI:1427070259
Name:PRUETT, STEPHEN J
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:J
Last Name:PRUETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3805B SPRING ST
Mailing Address - Street 2:SUITE 140
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53405-1641
Mailing Address - Country:US
Mailing Address - Phone:262-637-8835
Mailing Address - Fax:262-635-8027
Practice Address - Street 1:3805B SPRING ST
Practice Address - Street 2:SUITE 140
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53405-1641
Practice Address - Country:US
Practice Address - Phone:262-637-8835
Practice Address - Fax:262-635-8027
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2011-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1963-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38583200Medicaid
WI38583200Medicaid
WI000252480Medicare ID - Type Unspecified