MEDICARE: MR. DONALD SPRAGUE PENDER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0205X	Radiological Physics Physician	TRP143	FL

General Provider Information

NPI Number	:	1053664615
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DONALD SPRAGUE PENDER

Provider Business Mailing Address
First Line	:	390 NE 93RD ST
Second Line	:
City	:	MIAMI SHORES
State	:	FL
Zip	:	33138-2828
Country	:	US
Telephone Number	:	786-298-6639
Fax Number	:	954-730-2337

Provider Business Practice Location Address
First Line	:	3920 NW 49TH ST
Second Line	:
City	:	TAMARAC
State	:	FL
Zip	:	33309-3308
Country	:	US
Telephone Number	:	954-730-2333
Fax Number	:	954-730-2337

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/19/2012
Last Update Date	:	10/19/2012

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