Provider Demographics
NPI:1255322681
Name:PRENDERGAST, MARK L (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:L
Last Name:PRENDERGAST
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 SIGNAL HILL DRIVE EXT
Mailing Address - Street 2:PO BOX 1845
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28625-4353
Mailing Address - Country:US
Mailing Address - Phone:704-873-4277
Mailing Address - Fax:704-873-4511
Practice Address - Street 1:707 BRYANT ST
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-4142
Practice Address - Country:US
Practice Address - Phone:704-873-5224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2008-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC31358207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8966734Medicaid
NC8966734Medicaid
NCC86049Medicare UPIN