Provider Demographics
NPI:1801842844
Name:PENDYALA, PRASHANT (MD)
Entity Type:Individual
Prefix:
First Name:PRASHANT
Middle Name:
Last Name:PENDYALA
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 1:50 SANCTUARY CT
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14221-3963
Mailing Address - Country:US
Mailing Address - Phone:716-912-9595
Mailing Address - Fax:
Practice Address - Street 1:53 ELIZABETH DR
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14094-5226
Practice Address - Country:US
Practice Address - Phone:716-650-0373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-25
Last Update Date:2021-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001535207R00000X
NY241265207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02212706Medicaid
NY02212706Medicaid
H46006Medicare UPIN