Healthcare Provider Details

I. General information

NPI: 1407838477
Provider Name (Legal Business Name): WILLIAM JOHN PRENDERGAST III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/16/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1955 NW NORTHRUP ST
PORTLAND OR
97209-1614
US

IV. Provider business mailing address

11086 SE OAK ST
MILWAUKIE OR
97222-6692
US

V. Phone/Fax

Practice location:
  • Phone: 503-227-2020
  • Fax: 503-222-0614
Mailing address:
  • Phone: 503-557-2020
  • Fax: 503-344-5110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD07423
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: