Healthcare Provider Details

I. General information

NPI: 1942510672
Provider Name (Legal Business Name): BERNARD A. PRUDENCIO M.D.PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2010
Last Update Date: 10/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

673 THIRD AVE
WELAKA FL
32193-0619
US

IV. Provider business mailing address

673 THIRD AVE PO BOX 619
WELAKA FL
32193-0619
US

V. Phone/Fax

Practice location:
  • Phone: 386-467-9047
  • Fax: 386-467-8512
Mailing address:
  • Phone: 386-467-9047
  • Fax: 386-467-8512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: REBECCA PRUDENCIO
Title or Position: OFFICE MANAGER
Credential:
Phone: 386-467-9047