Provider Demographics
NPI:1548450588
Name:PRUDHOMME, REGAN MARQUIS (OD)
Entity type:Individual
Prefix:DR
First Name:REGAN
Middle Name:MARQUIS
Last Name:PRUDHOMME
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:REGAN
Other - Middle Name:SARAH
Other - Last Name:MARQUIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:194 BUCKLAND HILLS DR
Mailing Address - Street 2:SUITE 1106
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06042
Mailing Address - Country:US
Mailing Address - Phone:860-644-3364
Mailing Address - Fax:860-667-4377
Practice Address - Street 1:194 BUCKLAND HILLS DR
Practice Address - Street 2:SUITE 1106
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06042
Practice Address - Country:US
Practice Address - Phone:860-644-3364
Practice Address - Fax:860-667-4377
Is Sole Proprietor?:No
Enumeration Date:2007-07-26
Last Update Date:2015-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002721152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT410001230Medicare PIN