Basic Information
| Provider Information | |||||||||
| NPI: | 1649525684 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PRUETER | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1222 PATTERSON AVE | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454022682 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374962620 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1222 S PATTERSON BLVD STE 400 | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454022642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374962620 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2012 | ||||||||
| LastUpdateDate: | 03/12/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 34-011112 | OH | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 0103972 | 05 | OH | MEDICAID |