Provider Demographics
NPI:1265753248
Name:PENDARVIS, ALLEN E JR (MD)
Entity type:Individual
Prefix:DR
First Name:ALLEN
Middle Name:E
Last Name:PENDARVIS
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1064 GARDNER RD STE 112
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-5768
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1064 GARDNER RD STE 112
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-5768
Practice Address - Country:US
Practice Address - Phone:843-723-3441
Practice Address - Fax:843-805-4040
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-14
Last Update Date:2024-05-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC32696207L00000X
MA248435207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC326962Medicaid