Provider Demographics
NPI:1588697361
Name:PRUITT, JAMES C (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:C
Last Name:PRUITT
Suffix:
Gender:M
Credentials:MD
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 7638
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80537-0638
Mailing Address - Country:US
Mailing Address - Phone:970-749-2755
Mailing Address - Fax:970-259-2431
Practice Address - Street 1:75 S PAGOSA BLVD
Practice Address - Street 2:
Practice Address - City:PAGOSA SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81147-7910
Practice Address - Country:US
Practice Address - Phone:970-431-4131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO22652207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM01Y342OtherNM BCBS
COPRP07018OtherBCBS
CO01226521Medicaid
6003610001OtherPALMETTO DME
NMNM01Y342OtherNM BCBS
COC809691Medicare PIN
COD24142Medicare UPIN
COCO41007Medicare PIN