Provider Demographics
NPI:1508621053
Name:PENDERGRAST, JACOB MCGIMSEY
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:MCGIMSEY
Last Name:PENDERGRAST
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1190 DUNDAS STREET EAST
Mailing Address - Street 2:905
Mailing Address - City:TORONTO
Mailing Address - State:ONTARIO
Mailing Address - Zip Code:M4M0C5
Mailing Address - Country:CA
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3EC-306, 200 ELIZABETH STREET
Practice Address - Street 2:
Practice Address - City:TORONTO
Practice Address - State:ONTARIO
Practice Address - Zip Code:M4M0C5
Practice Address - Country:CA
Practice Address - Phone:416-340-4800
Practice Address - Fax:416-340-5410
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-14
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207RH0000X174400000X
VT207RH0000X207RH0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
No174400000XOther Service ProvidersSpecialist