Provider Demographics
NPI:1518151182
Name:PRUDHOMME, JEREMY EARL (OD)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:EARL
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 1:495 UNION ST STE 1082
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06706-1285
Mailing Address - Country:US
Mailing Address - Phone:203-591-8353
Mailing Address - Fax:
Practice Address - Street 1:495 UNION ST STE 1082
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06706-1285
Practice Address - Country:US
Practice Address - Phone:203-591-8353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-28
Last Update Date:2007-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2725152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist