Provider Demographics
NPI:1932104353
Name:PRUITT, ROGER DEVERN (DO)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:DEVERN
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 1:180 JOE WIMBERLEY BLVD
Mailing Address - Street 2:STE 102
Mailing Address - City:WIMBERLEY
Mailing Address - State:TX
Mailing Address - Zip Code:78676-6083
Mailing Address - Country:US
Mailing Address - Phone:512-847-7700
Mailing Address - Fax:512-847-7701
Practice Address - Street 1:180 JOE WIMBERLEY BLVD
Practice Address - Street 2:STE 102
Practice Address - City:WIMBERLEY
Practice Address - State:TX
Practice Address - Zip Code:78676-6083
Practice Address - Country:US
Practice Address - Phone:512-847-7700
Practice Address - Fax:512-847-7701
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL17062080A0000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX7061167OtherAETNA
TX0085HZOtherBLUE CROSS BLUE SHIELD
TX157905401Medicaid
TX0047IRMedicare ID - Type Unspecified