Provider Demographics
NPI:1952858482
Name:SY, PRUDENCIO CUPAT (IDC)
Entity Type:Individual
Prefix:
First Name:PRUDENCIO
Middle Name:CUPAT
Last Name:SY
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BLDG 159 NAVSUBASE NLON
Mailing Address - Street 2:NAVAL UNDERSEA MEDICAL INSTITUTE
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06349-5159
Mailing Address - Country:US
Mailing Address - Phone:860-694-2876
Mailing Address - Fax:
Practice Address - Street 1:BLDG 159 NAVSUBASE NLON
Practice Address - Street 2:NAVAL UNDERSEA MEDICAL INSTITUTE
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06349-5159
Practice Address - Country:US
Practice Address - Phone:860-694-2876
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman