Provider Demographics
NPI:1366587479
Name:PRUDENT, ROBERT MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:MICHAEL
Last Name:PRUDENT
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 1:675 SEMINOLE AVE NE
Mailing Address - Street 2:SUITE 305
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30307-3408
Mailing Address - Country:US
Mailing Address - Phone:404-685-3113
Mailing Address - Fax:
Practice Address - Street 1:675 SEMINOLE AVE NE
Practice Address - Street 2:SUITE 305
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30307-3408
Practice Address - Country:US
Practice Address - Phone:404-685-3113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0373402084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA26BDFQWMedicare ID - Type Unspecified
GAF39304Medicare UPIN