Provider Demographics
NPI:1841285947
Name:PRUDHON, GENE D (OD)
Entity type:Individual
Prefix:
First Name:GENE
Middle Name:D
Last Name:PRUDHON
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 1:1005 17TH ST
Mailing Address - Street 2:PO BOX 137
Mailing Address - City:BRODHEAD
Mailing Address - State:WI
Mailing Address - Zip Code:53520-1855
Mailing Address - Country:US
Mailing Address - Phone:608-897-2128
Mailing Address - Fax:608-897-3937
Practice Address - Street 1:1005 17TH ST
Practice Address - Street 2:
Practice Address - City:BRODHEAD
Practice Address - State:WI
Practice Address - Zip Code:53520-1855
Practice Address - Country:US
Practice Address - Phone:608-897-2128
Practice Address - Fax:608-897-3937
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1483152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38545800Medicaid
WI391904576017OtherBLUECROSS & BLUESHIELD
WIPRUDHGENOtherMERCYCARE
WI1006622OtherPHYSICIANS PLUS
WI1483OtherLICENSE #
WI38545800Medicaid
WIWI1948001Medicare PIN
WIPRUDHGENOtherMERCYCARE
WI000047153Medicare ID - Type Unspecified