Provider Demographics
NPI:1093721524
Name:PRENDERGAST, THOMAS JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:JOSEPH
Last Name:PRENDERGAST
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3710 SW US VETERANS HOSPITAL ROAD
Mailing Address - Street 2:P-3-PULM, PORTLAND VAMC
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-1034
Mailing Address - Country:US
Mailing Address - Phone:503-220-8262
Mailing Address - Fax:503-721-7852
Practice Address - Street 1:3710 SW US VETERANS HOSPITAL RD
Practice Address - Street 2:P-3-PULM
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-1034
Practice Address - Country:US
Practice Address - Phone:503-220-8262
Practice Address - Fax:503-721-7852
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2012-03-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NH9551207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0RE3859Medicaid
NH80003859Medicaid
F28939Medicare UPIN
VT0RE3859Medicaid