Provider Demographics
NPI:1295186419
Name:PRUDENCIO, JEFF (IDC)
Entity Type:Individual
Prefix:
First Name:JEFF
Middle Name:
Last Name:PRUDENCIO
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:JEFF
Other - Middle Name:
Other - Last Name:PRUDENCIO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:IDC
Mailing Address - Street 1:USS WHIRLWIND PC-11
Mailing Address - Street 2:UNIT 100298 BOX 1
Mailing Address - City:FPO
Mailing Address - State:AE
Mailing Address - Zip Code:09591
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:UNIT 100298 BOX 1
Practice Address - Street 2:USS WHIRLWIND PC-11
Practice Address - City:FPO
Practice Address - State:AE
Practice Address - Zip Code:09591-9800
Practice Address - Country:US
Practice Address - Phone:318-439-2358
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-29
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman