Provider Demographics
NPI:1780044362
Name:PRUDHOMME, IAN (MD)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:PRUDHOMME
Suffix:
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 1:2200 BERGQUIST DR STE 1
Mailing Address - Street 2:WHMC/GE-2200
Mailing Address - City:JBSA LACKLAND AFB
Mailing Address - State:TX
Mailing Address - Zip Code:78236-5300
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2200 BERGQUIST DR STE 1
Practice Address - Street 2:WHMC/GE-2200, JBSA LACKLAND AFB, TX
Practice Address - City:APO
Practice Address - State:AA
Practice Address - Zip Code:78236-5300
Practice Address - Country:US
Practice Address - Phone:423-943-2720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-25
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE30410207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology