Provider Demographics
NPI:1306823885
Name:PRENDERGAST, JANET S (DO)
Entity Type:Individual
Prefix:
First Name:JANET
Middle Name:S
Last Name:PRENDERGAST
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JANET
Other - Middle Name:S
Other - Last Name:LIBBING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1270 E STATE ROAD 205 STE 210
Practice Address - Street 2:SUITE 210
Practice Address - City:COLUMBIA CITY
Practice Address - State:IN
Practice Address - Zip Code:46725-8506
Practice Address - Country:US
Practice Address - Phone:260-248-9230
Practice Address - Fax:260-248-9249
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02002526A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000570549OtherANTHEM
IN200410430Medicaid
IN3937240025OtherMEDICARE DMEPOS
IN13459OtherPHYSICIANS HEALTH PLAN
7658349OtherAETNA
IN000000231124OtherANTHEM
IN080191000OtherRAILROAD MEDICARE
IN3937240002OtherMEDICARE DMEPOS
IN070900LMedicare PIN
IN000000231124OtherANTHEM
IN13459OtherPHYSICIANS HEALTH PLAN
IN080191000OtherRAILROAD MEDICARE