Provider Demographics
NPI:1609821453
Name:PRUDENICO AVENDANIO MDPA
Entity Type:Organization
Organization Name:PRUDENICO AVENDANIO MDPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PRUDENCIO
Authorized Official - Middle Name:C
Authorized Official - Last Name:AVENDANIO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-342-0921
Mailing Address - Street 1:PO BOX 8337
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79114-8337
Mailing Address - Country:US
Mailing Address - Phone:806-355-6593
Mailing Address - Fax:806-352-8774
Practice Address - Street 1:719 W COKE RD
Practice Address - Street 2:
Practice Address - City:WINNSBORO
Practice Address - State:TX
Practice Address - Zip Code:75494-3011
Practice Address - Country:US
Practice Address - Phone:903-342-5227
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF47452085R0202X, 2085R0204X, 2085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00JP90OtherBLUE CROSS
110999OtherSUPERIOR
110999OtherSUPERIOR
110999OtherSUPERIOR
E07987Medicare UPIN