Provider Demographics
NPI:1740395342
Name:PENDRACKY, LEON J (OD)
Entity Type:Individual
Prefix:DR
First Name:LEON
Middle Name:J
Last Name:PENDRACKY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 THREE SPRINGS DR # 3
Mailing Address - Street 2:
Mailing Address - City:WEIRTON
Mailing Address - State:WV
Mailing Address - Zip Code:26062-3827
Mailing Address - Country:US
Mailing Address - Phone:304-748-2055
Mailing Address - Fax:304-748-2054
Practice Address - Street 1:117 THREE SPRINGS DR # 3
Practice Address - Street 2:
Practice Address - City:WEIRTON
Practice Address - State:WV
Practice Address - Zip Code:26062-3827
Practice Address - Country:US
Practice Address - Phone:304-748-2055
Practice Address - Fax:304-748-2054
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV632-OD152W00000X
PAOEG000825152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0150384000Medicaid
PA111746Medicare PIN
WV0570540001Medicare NSC
WVT28797Medicare UPIN
WV0150384000Medicaid
PA0570540002Medicare NSC
WV0570540003Medicare NSC
WV0848282Medicare PIN