Provider Demographics
NPI:1023071933
Name:PRUETT, JON DAVIS (MD)
Entity type:Individual
Prefix:DR
First Name:JON
Middle Name:DAVIS
Last Name:PRUETT
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 1:8201 PRESTON RD STE 440
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75225-6209
Mailing Address - Country:US
Mailing Address - Phone:214-675-3227
Mailing Address - Fax:
Practice Address - Street 1:8201 PRESTON RD STE 440
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75225-6209
Practice Address - Country:US
Practice Address - Phone:214-675-3227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.15367R207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8AG440OtherBCBS
TXI68854Medicare UPIN
TX8J2207Medicare PIN