Basic Information
Provider Information | |||||||||
NPI: | 1194036624 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PRUETT | ||||||||
FirstName: | BENJAMIN | ||||||||
MiddleName: | JAMES | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7473 N INGRAM AVE STE 111 | ||||||||
Address2: |   | ||||||||
City: | FRESNO | ||||||||
State: | CA | ||||||||
PostalCode: | 937115856 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5592722934 | ||||||||
FaxNumber: | 5594856994 | ||||||||
Practice Location | |||||||||
Address1: | 6191 N THESTA ST | ||||||||
Address2: |   | ||||||||
City: | FRESNO | ||||||||
State: | CA | ||||||||
PostalCode: | 937105266 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5594364737 | ||||||||
FaxNumber: | 5594364738 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/30/2010 | ||||||||
LastUpdateDate: | 04/07/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/07/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 5101018915 | MI | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 390200000X |   | VA | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 2085R0204X | 20A14838 | CA | Y |   | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
No ID Information.