Healthcare Provider Details

I. General information

NPI: 1386964062
Provider Name (Legal Business Name): SPENCER ALLEN PRUITT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2010
Last Update Date: 06/14/2024
Certification Date: 06/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 S COULTER ST
AMARILLO TX
79106-1786
US

IV. Provider business mailing address

1400 S COULTER ST
AMARILLO TX
79106-1786
US

V. Phone/Fax

Practice location:
  • Phone: 806-414-9800
  • Fax: 806-354-5536
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License NumberMC-2916
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD.205315
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number62411
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License NumberQ1710
License Number StateTX
# 5
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number62411
License Number StateMN
# 6
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberQ1710
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: