Healthcare Provider Details

I. General information

NPI: 1588651020
Provider Name (Legal Business Name): TIMOTHY LEE PENDERGRASS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 01/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 TUSKEGEE BLVD 436 MDG CC STE 1B22
DOVER AFB DE
19902-5300
US

IV. Provider business mailing address

300 TUSKEGEE BLVD 436 MDG CC STE 1B22
DOVER AFB DE
19902-5300
US

V. Phone/Fax

Practice location:
  • Phone: 302-677-2525
  • Fax: 302-677-2526
Mailing address:
  • Phone: 302-677-2525
  • Fax: 302-677-2526

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number5757
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: