Provider Demographics
NPI:1093901761
Name:PRUDHOMME, DAVID LAWRENCE (OD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:LAWRENCE
Last Name:PRUDHOMME
Suffix:
Gender:M
Credentials:OD
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 821135
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39182-1135
Mailing Address - Country:US
Mailing Address - Phone:601-630-9199
Mailing Address - Fax:601-630-9192
Practice Address - Street 1:3505 PEMBERTON SQUARE BLVD
Practice Address - Street 2:SUITE 45
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-5537
Practice Address - Country:US
Practice Address - Phone:601-630-9199
Practice Address - Fax:601-630-9192
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-17
Last Update Date:2007-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSMS 579152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00880004Medicaid
MS410000288Medicare PIN