Provider Demographics
NPI:1700978889
Name:PRUITT, CHARLES (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:
Last Name:PRUITT
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Gender:M
Credentials:MD
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Mailing Address - Street 1:360 SIMPSON HWY 149
Mailing Address - Street 2:SUITE300
Mailing Address - City:MAGEE
Mailing Address - State:MS
Mailing Address - Zip Code:39111-3409
Mailing Address - Country:US
Mailing Address - Phone:601-849-1230
Mailing Address - Fax:601-849-1890
Practice Address - Street 1:360 SIMPSON HIGHWAY 149
Practice Address - Street 2:SUITE300
Practice Address - City:MAGEE
Practice Address - State:MS
Practice Address - Zip Code:39111-3841
Practice Address - Country:US
Practice Address - Phone:601-849-1230
Practice Address - Fax:601-849-1890
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2023-03-07
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Provider Licenses
StateLicense IDTaxonomies
MS06021207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00123423Medicaid
MSAP5866566OtherDEA #
MSAP5866566OtherDEA #
MSB66084Medicare UPIN