Provider Demographics
NPI:1619380334
Name:PRUDNICK, COLTON C (DO)
Entity Type:Individual
Prefix:
First Name:COLTON
Middle Name:C
Last Name:PRUDNICK
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:804 SERVICE RD STE A109B
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48824-7015
Mailing Address - Country:US
Mailing Address - Phone:517-355-4205
Mailing Address - Fax:517-364-8119
Practice Address - Street 1:4660 S HAGADORN RD STE 210
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-5353
Practice Address - Country:US
Practice Address - Phone:517-355-4205
Practice Address - Fax:517-364-8119
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-10
Last Update Date:2023-11-20
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Provider Licenses
StateLicense IDTaxonomies
MI5101025083208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5101021241OtherMI LICENSE