Provider Demographics
NPI:1871593996
Name:PRUDEN, SAMUEL J II (MD)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:J
Last Name:PRUDEN
Suffix:II
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:989 GOVERNORS LN STE 220
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40513-1175
Mailing Address - Country:US
Mailing Address - Phone:859-296-7546
Mailing Address - Fax:859-721-0829
Practice Address - Street 1:989 GOVERNORS LN STE 260
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40513-1175
Practice Address - Country:US
Practice Address - Phone:859-296-7546
Practice Address - Fax:859-721-0829
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY34192207ND0900X, 207Y00000X, 208200000X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000823142OtherANTHEM BCBS
KY64051196Medicaid
KY64051196Medicaid
H49077Medicare UPIN