Provider Demographics
NPI:1255425989
Name:PENDERGRASS, DESIREE BUEHLER (MD)
Entity type:Individual
Prefix:
First Name:DESIREE
Middle Name:BUEHLER
Last Name:PENDERGRASS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-815-8982
Mailing Address - Fax:
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-815-8982
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH4609208000000X, 2083P0901X
MS24712208000000X, 2083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05359595Medicaid
TX08907561OtherNM MEDICAID
TX8J1510OtherMEDICARE
TX132232307OtherTMHP
TX155349101OtherFIRSTCARE MEDICAID
TX8G6058OtherBC/BS
TX200101350AOtherOK MEDICARE
MS05359595Medicaid
TX200101350AOtherOK MEDICARE