Provider Demographics
NPI:1710015490
Name:PRUITT, BRYAN (MD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:PRUITT
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 1:8315 WALNUT HILL LN
Mailing Address - Street 2:SUITE 125
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-4218
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8315 WALNUT HILL LN
Practice Address - Street 2:SUITE 125
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4218
Practice Address - Country:US
Practice Address - Phone:214-363-6000
Practice Address - Fax:214-363-0068
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH1403208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery