Provider Demographics
NPI:1073509667
Name:PRUDENCIO, BERNADITO A (MD)
Entity Type:Individual
Prefix:DR
First Name:BERNADITO
Middle Name:A
Last Name:PRUDENCIO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:MR
Other - First Name:BERNARD
Other - Middle Name:A
Other - Last Name:PRUDENCIO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 619
Mailing Address - Street 2:673 THIRD AVE
Mailing Address - City:WELAKA
Mailing Address - State:FL
Mailing Address - Zip Code:32193-0619
Mailing Address - Country:US
Mailing Address - Phone:385-467-9047
Mailing Address - Fax:386-467-8512
Practice Address - Street 1:673 THIRD AVENUE
Practice Address - Street 2:
Practice Address - City:WELAKA
Practice Address - State:FL
Practice Address - Zip Code:32193-0619
Practice Address - Country:US
Practice Address - Phone:385-467-9047
Practice Address - Fax:386-467-8512
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-20
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME29872207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL037720100Medicaid
FL037720101Medicaid
FL037720101Medicaid
FL54045Medicare ID - Type Unspecified