Provider Demographics
NPI:1821253303
Name:PENDRAK BUSH, MICHELE ROSE (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHELE
Middle Name:ROSE
Last Name:PENDRAK BUSH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:MICHELE
Other - Middle Name:ROSE
Other - Last Name:PENDRAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:PO BOX 310
Mailing Address - Street 2:155 LITTLE CONESTOGA RD SUITE #5
Mailing Address - City:EAGLE
Mailing Address - State:PA
Mailing Address - Zip Code:19480
Mailing Address - Country:US
Mailing Address - Phone:610-458-9800
Mailing Address - Fax:610-458-9806
Practice Address - Street 1:155 LITTLE CONESTOGA RD
Practice Address - Street 2:SUITE #5
Practice Address - City:EAGLE
Practice Address - State:PA
Practice Address - Zip Code:19480
Practice Address - Country:US
Practice Address - Phone:610-458-9800
Practice Address - Fax:610-458-9806
Is Sole Proprietor?:No
Enumeration Date:2008-07-23
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG002095152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U02249Medicare UPIN