Individual
SAMUEL J PRUDEN II
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
989 GOVERNORS LN STE 260, LEXINGTON, KY 40513-1175
(859) 296-7546
(859) 721-0829
Mailing address
989 GOVERNORS LN STE 220, LEXINGTON, KY 40513-1175
(859) 296-7546
(859) 721-0829
Taxonomy
Speciality
Code
Description
License number
State
207ND0101X
MOHS-Micrographic Surgery Physician
Primary
34192
KY
207ND0900X
Dermatopathology Physician
34192
KY
207Y00000X
Otolaryngology Physician
34192
KY
208200000X
Plastic Surgery Physician
34192
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000823142
ANTHEM BCBS
KY
05
—
64051196
—
KY
Enumeration date
07/29/2005
Last updated
12/15/2022
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