Healthcare Provider Details

I. General information

NPI: 1376549857
Provider Name (Legal Business Name): WARREN JOSEF PENDERGAST JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 08/03/2024
Certification Date: 06/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 HOMEWOOD CT STE 201
RALEIGH NC
27609-5732
US

IV. Provider business mailing address

4700 HOMEWOOD CT STE 220
RALEIGH NC
27609-5732
US

V. Phone/Fax

Practice location:
  • Phone: 919-787-7125
  • Fax: 919-781-9952
Mailing address:
  • Phone: 919-787-7125
  • Fax: 919-781-9952

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number31889
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: