Healthcare Provider Details

I. General information

NPI: 1497751887
Provider Name (Legal Business Name): PRUDENCIO CUISON LUCERO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 04/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 STONEWOOD DR STE 110
WEXFORD PA
15090-8386
US

IV. Provider business mailing address

1000 STONEWOOD DR SUITE 110
WEXFORD PA
15090-8386
US

V. Phone/Fax

Practice location:
  • Phone: 724-940-6000
  • Fax: 724-940-6006
Mailing address:
  • Phone: 724-940-6000
  • Fax: 724-940-6006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberMD050308L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: