Provider Demographics
NPI:1588651020
Name:PENDERGRASS, TIMOTHY LEE (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:LEE
Last Name:PENDERGRASS
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:300 TUSKEGEE BLVD
Mailing Address - Street 2:436 MDG CC STE 1B22
Mailing Address - City:DOVER AFB
Mailing Address - State:DE
Mailing Address - Zip Code:19902-5300
Mailing Address - Country:US
Mailing Address - Phone:302-677-2525
Mailing Address - Fax:302-677-2526
Practice Address - Street 1:300 TUSKEGEE BLVD
Practice Address - Street 2:436 MDG CC STE 1B22
Practice Address - City:DOVER AFB
Practice Address - State:DE
Practice Address - Zip Code:19902-5300
Practice Address - Country:US
Practice Address - Phone:302-677-2525
Practice Address - Fax:302-677-2526
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ND57572085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology