Healthcare Provider Details

I. General information

NPI: 1295759108
Provider Name (Legal Business Name): THOMAS PRENDERGAST D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 06/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 SILVER SW SUITE A
ALBUQUERQUE NM
87114-5218
US

IV. Provider business mailing address

PO BOX 661597
ARCADIA CA
91066-1597
US

V. Phone/Fax

Practice location:
  • Phone: 800-893-9698
  • Fax: 337-371-4738
Mailing address:
  • Phone: 626-447-0296
  • Fax: 626-447-6057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA716-80
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: