Provider Demographics
NPI:1053411546
Name:PITTMAN, BOBBY W (MD)
Entity type:Individual
Prefix:DR
First Name:BOBBY
Middle Name:W
Last Name:PITTMAN
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 1:703 US HIGHWAY 90 E
Mailing Address - Street 2:SUITE 108
Mailing Address - City:CASTROVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78009-5246
Mailing Address - Country:US
Mailing Address - Phone:417-773-1703
Mailing Address - Fax:
Practice Address - Street 1:703 US HIGHWAY 90 E
Practice Address - Street 2:SUITE 108
Practice Address - City:CASTROVILLE
Practice Address - State:TX
Practice Address - Zip Code:78009-5246
Practice Address - Country:US
Practice Address - Phone:417-773-1703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-24
Last Update Date:2012-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN5339207Q00000X
MOMD115594207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
129203OtherBLUE CROSS OF MO
MO205252901Medicaid
TX214999901Medicaid
TX214999901Medicaid
002013391Medicare PIN
129203OtherBLUE CROSS OF MO