Provider Demographics
NPI:1265775993
Name:PRUDOM, JASON SCOTT (MD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:SCOTT
Last Name:PRUDOM
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:GREATER MILWAUKEE CRITICAL CARE AND PULMONARY ASSOCIATE
Mailing Address - Street 2:PO BOX 070520
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53207-0520
Mailing Address - Country:US
Mailing Address - Phone:414-649-3810
Mailing Address - Fax:262-240-0841
Practice Address - Street 1:3201 S 16TH ST STE 2015
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-4532
Practice Address - Country:US
Practice Address - Phone:414-649-3810
Practice Address - Fax:262-240-0841
Is Sole Proprietor?:No
Enumeration Date:2013-04-01
Last Update Date:2019-03-25
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Provider Licenses
StateLicense IDTaxonomies
WI63600-20207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100042547Medicaid