Provider Demographics
NPI:1134280779
Name:PENDLETON, MICHAEL J (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:PENDLETON
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 1:4210 WEBER RD STE 2
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78411-3666
Mailing Address - Country:US
Mailing Address - Phone:361-225-0719
Mailing Address - Fax:361-225-0705
Practice Address - Street 1:4210 WEBER RD STE 2
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-3666
Practice Address - Country:US
Practice Address - Phone:361-225-0719
Practice Address - Fax:361-225-0705
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL4091207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0013MTOtherBLUE CROSS
TX611887Medicare ID - Type Unspecified
TXH47320Medicare UPIN