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NPI Code Detail

MEDICARE: DR. BENJAMIN EDWARD PENDERGRASS O.D.

MEDICARE: DR. BENJAMIN EDWARD PENDERGRASS O.D.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1152W00000XOptometristSC-62-TA-905AL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1396030912
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. BENJAMIN EDWARD PENDERGRASS O.D.
Provider Business Mailing Address
First Line : 15933 CLAYTON RD
Second Line : SUITE 201
City : BALLWIN
State : MO
Zip : 63011-2172
Country : US
Telephone Number : 636-200-4393
Fax Number : 636-527-0766
Provider Business Practice Location Address
First Line : 600 WASHINGTON ST NW
Second Line :
City : HUNTSVILLE
State : AL
Zip : 35801-4751
Country : US
Telephone Number : 256-533-6838
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/10/2011
Last Update Date : 11/15/2016

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Directions to “ DR. BENJAMIN EDWARD PENDERGRASS O.D.” Practice Location

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