Provider Demographics
NPI:1710985254
Name:PENDERGRASS, LANDON (MD)
Entity Type:Individual
Prefix:
First Name:LANDON
Middle Name:
Last Name:PENDERGRASS
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 1:777 WASHINGTON AVE
Mailing Address - Street 2:SUITE 410
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38105-4550
Mailing Address - Country:US
Mailing Address - Phone:901-523-2945
Mailing Address - Fax:
Practice Address - Street 1:777 WASHINGTON AVE
Practice Address - Street 2:SUITE 410
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38105-4550
Practice Address - Country:US
Practice Address - Phone:901-523-2945
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN19808208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3046506Medicaid
TN3046506Medicaid