Provider Demographics
NPI:1295759108
Name:PRENDERGAST, THOMAS (DO)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:PRENDERGAST
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 661597
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91066-1597
Mailing Address - Country:US
Mailing Address - Phone:626-447-0296
Mailing Address - Fax:626-447-6057
Practice Address - Street 1:625 SILVER SW
Practice Address - Street 2:SUITE A
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-5218
Practice Address - Country:US
Practice Address - Phone:800-893-9698
Practice Address - Fax:337-371-4738
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA716-80207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX60300Medicaid
CA020A60303Medicare PIN