Provider Demographics
NPI:1033272448
Name:PRENDERGAST, LAURA (DO)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:PRENDERGAST
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:158 49 84TH STREET
Mailing Address - Street 2:
Mailing Address - City:HOWARD BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11414
Mailing Address - Country:US
Mailing Address - Phone:718-322-7425
Mailing Address - Fax:718-323-5541
Practice Address - Street 1:158-89 84TH ST
Practice Address - Street 2:
Practice Address - City:HOWARD BEACH
Practice Address - State:NY
Practice Address - Zip Code:11414
Practice Address - Country:US
Practice Address - Phone:718-322-7425
Practice Address - Fax:718-323-5541
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY228028208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics