Provider Demographics
NPI:1588602122
Name:PENDSE, PRABHAKAR DAMODAR (MD)
Entity type:Individual
Prefix:DR
First Name:PRABHAKAR
Middle Name:DAMODAR
Last Name:PENDSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 602484
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2484
Mailing Address - Country:US
Mailing Address - Phone:910-815-5830
Mailing Address - Fax:910-815-5698
Practice Address - Street 1:2131 S 17TH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7407
Practice Address - Country:US
Practice Address - Phone:910-815-5830
Practice Address - Fax:910-815-5698
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-04
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC17733208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC4098357OtherAETNA
NC1588602122Medicaid
NC183728OtherMEDCOST
NC8966735Medicaid
NC66735OtherBCBS NC
NC183728OtherMEDCOST
D62835Medicare UPIN