Provider Demographics
NPI:1326783671
Name:PRENDERGAST, MACKENZIE REED JOYCE (DO)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:REED JOYCE
Last Name:PRENDERGAST
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:SAN ANTONIO MILITARY MEDICAL CENTER, MCHE-EMR
Mailing Address - Street 2:3551 ROGER BROOKE DR
Mailing Address - City:JBSA-FORT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234-4504
Mailing Address - Country:US
Mailing Address - Phone:210-916-4789
Mailing Address - Fax:
Practice Address - Street 1:SAN ANTONIO MILITARY MEDICAL CENTER, MCHE-EMR
Practice Address - Street 2:3551 ROGER BROOKE DR
Practice Address - City:JBSA-FORT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-4504
Practice Address - Country:US
Practice Address - Phone:210-916-4789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-02
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
171000000X
VA0102208422208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No171000000XOther Service ProvidersMilitary Health Care Provider