Provider Demographics
NPI:1932541786
Name:PRUDENT MEDICAL ASSOCIATES LLC
Entity Type:Organization
Organization Name:PRUDENT MEDICAL ASSOCIATES LLC
Other - Org Name:PRUDENT MEDICAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:I
Authorized Official - Last Name:OKONOFUA
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:301-254-8509
Mailing Address - Street 1:7100 BALTIMORE AVE STE 510
Mailing Address - Street 2:
Mailing Address - City:COLLEGE PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20740-3641
Mailing Address - Country:US
Mailing Address - Phone:240-467-5739
Mailing Address - Fax:240-467-5795
Practice Address - Street 1:7100 BALTIMORE AVE STE 510
Practice Address - Street 2:
Practice Address - City:COLLEGE PARK
Practice Address - State:MD
Practice Address - Zip Code:20740-3641
Practice Address - Country:US
Practice Address - Phone:240-467-5739
Practice Address - Fax:240-467-5795
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-22
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN1003033363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC080802600Medicaid
DC080802600Medicaid