Provider Demographics
NPI:1013249549
Name:MARCELIN, PRUDENT (MD)
Entity type:Individual
Prefix:
First Name:PRUDENT
Middle Name:
Last Name:MARCELIN
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 1:670 N ORLANDO AVE STE 1012
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-4465
Mailing Address - Country:US
Mailing Address - Phone:954-557-8701
Mailing Address - Fax:
Practice Address - Street 1:670 N ORLANDO AVE STE 1012
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-4465
Practice Address - Country:US
Practice Address - Phone:407-790-7870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-09
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME105170207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1013249549Medicaid
FL1093012049Medicare PIN
FL1093012049Medicare UPIN
FL1013249549Medicaid
FL1093012049Medicare NSC