Provider Demographics
NPI:1477519361
Name:PENDRAK, ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:PENDRAK
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 1:6500 CRILL AVE
Mailing Address - Street 2:
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177-9230
Mailing Address - Country:US
Mailing Address - Phone:386-326-0575
Mailing Address - Fax:386-326-0571
Practice Address - Street 1:6500 CRILL AVE
Practice Address - Street 2:
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-9230
Practice Address - Country:US
Practice Address - Phone:386-326-0575
Practice Address - Fax:386-326-0571
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2019-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2005-0209208D00000X
FLME85025207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLNVEXFOtherBCBS
NMP00221334OtherRAILROAD MEDICARE
NM00NM009V36OtherBCBS
NM26351232Medicaid
NMP00221334OtherRAILROAD MEDICARE
NM00NM009V36OtherBCBS