Provider Demographics
NPI:1275571861
Name:PRUD'HOMME, JOSEPH LYNN SR (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:LYNN
Last Name:PRUD'HOMME
Suffix:SR
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 1:1015 E IDEL ST
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-2025
Mailing Address - Country:US
Mailing Address - Phone:903-592-8301
Mailing Address - Fax:903-592-7646
Practice Address - Street 1:1015 E IDEL ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2025
Practice Address - Country:US
Practice Address - Phone:903-592-8301
Practice Address - Fax:903-592-7646
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD0261174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXB25667Medicare UPIN