Healthcare Provider Details

I. General information

NPI: 1437153459
Provider Name (Legal Business Name): JUDITH PENDLETON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2005
Last Update Date: 03/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1445 W CHANDLER BLVD BLDG B10
CHANDLER AZ
85224-5204
US

IV. Provider business mailing address

1445 W CHANDLER BLVD BLDG B10
CHANDLER AZ
85224-5204
US

V. Phone/Fax

Practice location:
  • Phone: 480-385-5055
  • Fax: 480-385-5054
Mailing address:
  • Phone: 480-385-5055
  • Fax: 480-385-5054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25070
License Number StateAZ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier389777
Identifier TypeMEDICAID
Identifier StateAZ
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: