Provider Demographics
NPI:1649313867
Name:PRUDHOMME, GERALD DONALD (OD)
Entity type:Individual
Prefix:DR
First Name:GERALD
Middle Name:DONALD
Last Name:PRUDHOMME
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 MEEKER RD
Mailing Address - Street 2:
Mailing Address - City:VESTAL
Mailing Address - State:NY
Mailing Address - Zip Code:13850-3230
Mailing Address - Country:US
Mailing Address - Phone:607-754-8743
Mailing Address - Fax:607-798-9009
Practice Address - Street 1:601-635 HARRY L DR
Practice Address - Street 2:SUITE 55
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-1246
Practice Address - Country:US
Practice Address - Phone:607-797-3519
Practice Address - Fax:607-798-9009
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYT003782-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01068060Medicaid
NYU21407Medicare UPIN
NY01068060Medicaid