MEDICARE: DR. ROGER DEVERN PRUITT D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2080A0000X	Pediatric Adolescent Medicine Physician	L1706	TX
2	208000000X	Pediatrics Physician	L1706	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7061167	OTHER	TX	AETNA
2	0085HZ	OTHER	TX	BLUE CROSS BLUE SHIELD
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1932104353
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROGER DEVERN PRUITT D.O.

Provider Business Mailing Address
First Line	:	180 JOE WIMBERLEY BLVD
Second Line	:	STE 102
City	:	WIMBERLEY
State	:	TX
Zip	:	78676-6083
Country	:	US
Telephone Number	:	512-847-7700
Fax Number	:	512-847-7701

Provider Business Practice Location Address
First Line	:	180 JOE WIMBERLEY BLVD
Second Line	:	STE 102
City	:	WIMBERLEY
State	:	TX
Zip	:	78676-6083
Country	:	US
Telephone Number	:	512-847-7700
Fax Number	:	512-847-7701

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/14/2005
Last Update Date	:	02/09/2022

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Directions to “ DR. ROGER DEVERN PRUITT D.O.” Practice Location

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