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General NPI Number Information
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NPI Number | 1871593996
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Entity Type | Individual
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Provider Name | SAMUEL J PRUDEN II MD
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Gender | Male
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Dates
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Enumeration Date | 07/29/2005
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Last Update Date | 12/15/2022
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Provider Practice Location Address
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Address Line | 989 GOVERNORS LN STE 260
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City | LEXINGTON
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State | KY
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Zip | 40513-1175
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Country | US
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Telephone | 859-296-7546
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Fax | 859-721-0829
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Provider Business Mailing Address
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Address Line | 989 GOVERNORS LN STE 220
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City | LEXINGTON
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State | KY
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Zip | 40513-1175
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Country | US
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Telephone | 859-296-7546
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Fax | 859-721-0829
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207ND0900X
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Taxonomy Name | Dermatopathology Physician
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License Number | 34192
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License Number State | KY
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Taxonomy #2
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Taxonomy Code | 207Y00000X
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Taxonomy Name | Otolaryngology Physician
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License Number | 34192
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License Number State | KY
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Taxonomy #3
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Taxonomy Code | 208200000X
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Taxonomy Name | Plastic Surgery Physician
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License Number | 34192
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License Number State | KY
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Taxonomy #4
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Taxonomy Code | 207ND0101X
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Taxonomy Name | MOHS-Micrographic Surgery Physician
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License Number | 34192
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License Number State | KY
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