Provider Demographics
NPI:1295828960
Name:PENDERGRAST, THOMAS LEE (OD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:LEE
Last Name:PENDERGRAST
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1232 PLANTATION DR
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32404-8637
Mailing Address - Country:US
Mailing Address - Phone:850-874-9803
Mailing Address - Fax:
Practice Address - Street 1:725 N TYNDALL PKWY
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32404-3219
Practice Address - Country:US
Practice Address - Phone:850-785-3426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOP2933152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL20664Medicare ID - Type Unspecified
FL60899Medicare UPIN