Provider Demographics
NPI:1831554195
Name:PRUDENT, JOSHUA
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
Last Name:PRUDENT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 LONGWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-5724
Mailing Address - Country:US
Mailing Address - Phone:617-355-6000
Mailing Address - Fax:
Practice Address - Street 1:55 FOGG RD
Practice Address - Street 2:
Practice Address - City:S WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02190-2432
Practice Address - Country:US
Practice Address - Phone:781-624-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-30
Last Update Date:2025-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1024936208000000X
OH351462292080P0204X, 2080P0204X
MDP635440441528390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0500102Medicaid