1619380334 NPI number — COLTON C PRUDNICK DO

Table of content: COLTON C PRUDNICK DO (NPI 1619380334)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619380334 NPI number — COLTON C PRUDNICK DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PRUDNICK
Provider First Name:
COLTON
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619380334
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/20/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
804 SERVICE RD STE A109B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAST LANSING
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48824-7015
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-355-4205
Provider Business Mailing Address Fax Number:
517-364-8119

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4660 S HAGADORN RD STE 210
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAST LANSING
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48823-5353
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-355-4205
Provider Business Practice Location Address Fax Number:
517-364-8119
Provider Enumeration Date:
06/10/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208800000X , with the licence number:  5101025083 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)