Provider Demographics
NPI:1942510672
Name:BERNARD A. PRUDENCIO M.D.PA
Entity Type:Organization
Organization Name:BERNARD A. PRUDENCIO M.D.PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:PRUDENCIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-467-9047
Mailing Address - Street 1:673 THIRD AVE
Mailing Address - Street 2:PO BOX 619
Mailing Address - City:WELAKA
Mailing Address - State:FL
Mailing Address - Zip Code:32193-0619
Mailing Address - Country:US
Mailing Address - Phone:386-467-9047
Mailing Address - Fax:386-467-8512
Practice Address - Street 1:673 THIRD AVE
Practice Address - Street 2:
Practice Address - City:WELAKA
Practice Address - State:FL
Practice Address - Zip Code:32193-0619
Practice Address - Country:US
Practice Address - Phone:386-467-9047
Practice Address - Fax:386-467-8512
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-15
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty