Provider Demographics
NPI:1548217896
Name:PENDLEY, DAVID SHANE (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:SHANE
Last Name:PENDLEY
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:PO BOX 555
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39533-0555
Mailing Address - Country:US
Mailing Address - Phone:228-868-9641
Mailing Address - Fax:
Practice Address - Street 1:4500 13TH ST
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2515
Practice Address - Country:US
Practice Address - Phone:228-867-4000
Practice Address - Fax:251-435-6478
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00026907207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02936207Medicaid
MS$$$$$$$$$BOtherBCBS
MS302I115920Medicare PIN
MS512I110310Medicare PIN
MS02936207Medicaid