Provider Demographics
NPI:1750377412
Name:PENTECOST, PERCY M (MD)
Entity type:Individual
Prefix:
First Name:PERCY
Middle Name:M
Last Name:PENTECOST
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 1:3016 MACKLAND AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-2018
Mailing Address - Country:US
Mailing Address - Phone:505-399-0890
Mailing Address - Fax:505-448-0778
Practice Address - Street 1:3016 MACKLAND AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-2018
Practice Address - Country:US
Practice Address - Phone:505-399-0890
Practice Address - Fax:505-448-0778
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2004-0754207QG0300X, 207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM32777337Medicaid
NMI36535Medicare UPIN
348522702Medicare PIN