Healthcare Provider Details

I. General information

NPI: 1124047097
Provider Name (Legal Business Name): BRIAN T. PRUITT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 10/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 WALLACE BLVD
AMARILLO TX
79106-1794
US

IV. Provider business mailing address

PO BOX 840048
DALLAS TX
75284-0048
US

V. Phone/Fax

Practice location:
  • Phone: 806-212-4673
  • Fax: 806-352-8890
Mailing address:
  • Phone: 806-212-4673
  • Fax: 806-352-8890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License NumberG1161
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: