Provider Demographics
NPI:1093497588
Name:TAM, PRUDENCE (OD)
Entity type:Individual
Prefix:DR
First Name:PRUDENCE
Middle Name:
Last Name:TAM
Suffix:
Gender:
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19071 BEAR VALLEY RD STE 3
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92308-2718
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8977 FOOTHILL BLVD STE C
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3498
Practice Address - Country:US
Practice Address - Phone:909-987-4919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-03
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35217152W00000X, 152WV0400X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy