Provider Demographics
NPI:1174567812
Name:PRUITT, JAMON R (MD)
Entity type:Individual
Prefix:DR
First Name:JAMON
Middle Name:R
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 1:2900 MEDICAL CENTER PKWY
Mailing Address - Street 2:SUITE 240B
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-3204
Mailing Address - Country:US
Mailing Address - Phone:479-553-2200
Mailing Address - Fax:479-553-2909
Practice Address - Street 1:2900 MEDICAL CENTER PKWY
Practice Address - Street 2:SUITE 240B
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-3204
Practice Address - Country:US
Practice Address - Phone:479-553-2200
Practice Address - Fax:479-553-2909
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC8298207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR180380000OtherQUAL CHOICE
AR5005701OtherAETNA
MO204813307Medicaid
AR135004001Medicaid
AR1900365OtherUNITED HEALTHCARE
OK100077970AMedicaid
ARC8298OtherARKANSAS STATE LICENSE
ARC8298OtherARKANSAS STATE LICENSE
ARG53034Medicare UPIN
AR135004001Medicaid
AR180380000OtherQUAL CHOICE