Provider Demographics
NPI:1992939458
Name:PRUITT, JEREMY EDWARD (IDC)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:EDWARD
Last Name:PRUITT
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 SYLVESTER RD
Mailing Address - Street 2:COMCMRON TWO BLDG. 139
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92106-3521
Mailing Address - Country:US
Mailing Address - Phone:619-524-9654
Mailing Address - Fax:
Practice Address - Street 1:USS WARRIOR MCM 10
Practice Address - Street 2:CREW CONSTANT - EH01
Practice Address - City:FPO
Practice Address - State:AA
Practice Address - Zip Code:34093-1930
Practice Address - Country:US
Practice Address - Phone:361-385-0592
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-12
Last Update Date:2009-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman