Provider Demographics
NPI:1689645657
Name:PRUITT, CHARLES BART (DO)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:BART
Last Name:PRUITT
Suffix:
Gender:M
Credentials:DO
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 12251
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4013
Mailing Address - Country:US
Mailing Address - Phone:903-342-9800
Mailing Address - Fax:903-342-9809
Practice Address - Street 1:719 W COKE RD
Practice Address - Street 2:BUILDING 2
Practice Address - City:WINNSBORO
Practice Address - State:TX
Practice Address - Zip Code:75494-3060
Practice Address - Country:US
Practice Address - Phone:903-342-9800
Practice Address - Fax:903-342-9809
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-30
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK3403207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX111772304Medicaid
TX752771569005OtherTRICARE
TX86424FOtherBCBS
TX320277YV0UMedicare PIN
TX320276Medicare PIN
TX86424FOtherBCBS
TXP01005230Medicare PIN
TXP00345840Medicare PIN
TX752771569005OtherTRICARE