Provider Demographics
NPI:1073682472
Name:PRUITT, ENAS L (MD)
Entity Type:Individual
Prefix:DR
First Name:ENAS
Middle Name:L
Last Name:PRUITT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4515 SETON CENTER PKWY
Mailing Address - Street 2:SUITE 215 CREDENTIALING
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-5290
Mailing Address - Country:US
Mailing Address - Phone:512-231-5548
Mailing Address - Fax:512-406-6216
Practice Address - Street 1:801 E WHITESTONE BLVD STE B
Practice Address - Street 2:
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-9040
Practice Address - Country:US
Practice Address - Phone:512-259-3467
Practice Address - Fax:512-406-7303
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM3701207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX208669608OtherARC MEDICAID ROT
TX208669609OtherARC MEDICAID TRAVIS
TX334450YKXYOtherMEDICARE WILLIAMSON COUNTY
TX208669603Medicaid
TX208669604Medicaid
TX208669605Medicaid
TX334450YKXVOtherMEDICARE TRAVIS COUNTY
TX8CN866OtherBCBS
TXTXB118276Medicare PIN
TXTXB117169Medicare PIN