Healthcare Provider Details

I. General information

NPI: 1255851200
Provider Name (Legal Business Name): REGIONAL DERMATOLOGY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

989 GOVERNORS LN STE 220
LEXINGTON KY
40513-1175
US

IV. Provider business mailing address

989 GOVERNORS LN STE 220
LEXINGTON KY
40513-1175
US

V. Phone/Fax

Practice location:
  • Phone: 859-296-7546
  • Fax: 859-721-0829
Mailing address:
  • Phone: 859-296-7546
  • Fax: 859-721-0829

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number34192
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number34192
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number34192
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number34192
License Number StateKY

VIII. Authorized Official

Name: DR. SAMUEL J PRUDEN II
Title or Position: PRESIDENT
Credential: MD
Phone: 859-296-7546