Healthcare Provider Details

I. General information

NPI: 1629056205
Provider Name (Legal Business Name): LEON PENDERGRAPH JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47149 BUSE RD BLDG 1370
PATUXENT RIVER MD
20670-1540
US

IV. Provider business mailing address

47149 BUSE RD BLDG 1370
PATUXENT RIVER MD
20670-1540
US

V. Phone/Fax

Practice location:
  • Phone: 301-342-9503
  • Fax: 301-342-4718
Mailing address:
  • Phone: 301-342-9503
  • Fax: 301-342-4718

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD63156
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: