Provider Demographics
NPI:1376590588
Name:PRUDENCIO, JOSE N JR (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:N
Last Name:PRUDENCIO
Suffix:JR
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 1:815 SIR THOMAS CT STE 200
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17109-4839
Mailing Address - Country:US
Mailing Address - Phone:717-724-0720
Mailing Address - Fax:717-724-0730
Practice Address - Street 1:815 SIR THOMAS CT STE 200
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17109-4839
Practice Address - Country:US
Practice Address - Phone:717-724-0720
Practice Address - Fax:717-724-0730
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD035222E208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAB37823Medicare UPIN
PA132550Medicare ID - Type Unspecified