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NPI Code Detail

MEDICARE: DR. THOMAS LEE PENDERGRAST O.D.

MEDICARE: DR. THOMAS LEE PENDERGRAST O.D.
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
1152W00000XOptometristOP2933FL

General Provider Information

NPI Number : 1295828960
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. THOMAS LEE PENDERGRAST O.D.
Provider Business Mailing Address
First Line : 1232 PLANTATION DR
Second Line :
City : PANAMA CITY
State : FL
Zip : 32404-8637
Country : US
Telephone Number : 850-874-9803
Fax Number :
Provider Business Practice Location Address
First Line : 725 N TYNDALL PKWY
Second Line :
City : PANAMA CITY
State : FL
Zip : 32404-3219
Country : US
Telephone Number : 850-785-3426
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/02/2006
Last Update Date : 07/08/2007

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