Provider Demographics
NPI:1124047097
Name:PRUITT, BRIAN T (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:T
Last Name:PRUITT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 840048
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-0048
Mailing Address - Country:US
Mailing Address - Phone:806-212-4673
Mailing Address - Fax:806-352-8890
Practice Address - Street 1:1500 WALLACE BLVD
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-1794
Practice Address - Country:US
Practice Address - Phone:806-212-4673
Practice Address - Fax:806-352-8890
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXG1161207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX269051YNR6OtherMEDICARE
TX137142911Medicaid
TXB25670Medicare UPIN