Provider Demographics
NPI:1528270816
Name:PRUDHOMME, BRYAN J (MD)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:J
Last Name:PRUDHOMME
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 632476
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-2476
Mailing Address - Country:US
Mailing Address - Phone:423-794-5540
Mailing Address - Fax:423-926-3187
Practice Address - Street 1:301 MED TECH PKWY
Practice Address - Street 2:STE. 180
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604
Practice Address - Country:US
Practice Address - Phone:423-794-5540
Practice Address - Fax:423-926-3187
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN42204208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3000368Medicaid