Provider Demographics
NPI:1912085259
Name:GOURGUECHON, PRUDENCE L (MD)
Entity Type:Individual
Prefix:DR
First Name:PRUDENCE
Middle Name:L
Last Name:GOURGUECHON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 W FRONTAGE RD
Mailing Address - Street 2:SUTIE 2120
Mailing Address - City:NORTHFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60093-1250
Mailing Address - Country:US
Mailing Address - Phone:847-441-1395
Mailing Address - Fax:
Practice Address - Street 1:540 W FRONTAGE RD
Practice Address - Street 2:SUTIE 2120
Practice Address - City:NORTHFIELD
Practice Address - State:IL
Practice Address - Zip Code:60093-1250
Practice Address - Country:US
Practice Address - Phone:847-441-1395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
691541Medicare UPIN