Provider Demographics
NPI:1871656710
Name:PENDLETON, MIRIAM R (OD)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:R
Last Name:PENDLETON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1100 EISENHOWER DR STE 4A
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-3926
Mailing Address - Country:US
Mailing Address - Phone:912-920-4747
Mailing Address - Fax:912-920-8055
Practice Address - Street 1:1100 EISENHOWER DR STE 4A
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-3926
Practice Address - Country:US
Practice Address - Phone:912-920-4747
Practice Address - Fax:912-920-8055
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-008921152W00000X
GAOPT002373152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist