Provider Demographics
NPI:1326030024
Name:PENDLETON, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:PENDLETON
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 1:1179 N MCDOWELL BLVD
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-6559
Mailing Address - Country:US
Mailing Address - Phone:707-559-7500
Mailing Address - Fax:707-559-7620
Practice Address - Street 1:1179 N MCDOWELL BLVD
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-6559
Practice Address - Country:US
Practice Address - Phone:707-559-7500
Practice Address - Fax:707-559-7620
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA91072207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC70696FMedicaid
CA1326030024Medicaid
CABCP70696FMedicaid
CAZZZ18742ZOtherISSUER MEDICARE
CAHAP70696FMedicaid
CABCP70696FMedicaid
CAI45453Medicare UPIN