Provider Demographics
NPI:1245219757
Name:PRUEITT, ROUHOLLAH F (MD)
Entity Type:Individual
Prefix:DR
First Name:ROUHOLLAH
Middle Name:F
Last Name:PRUEITT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 201606
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-1606
Mailing Address - Country:US
Mailing Address - Phone:972-519-1940
Mailing Address - Fax:
Practice Address - Street 1:500 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75057-3641
Practice Address - Country:US
Practice Address - Phone:972-420-1576
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL9855207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8C0846OtherBCBS
TXP00323510OtherRAILROAD
TX168848304Medicaid
TX168848303Medicaid
TXTXB159707Medicare PIN
TX168848303Medicaid
TX8D8197Medicare PIN