Basic Information
| Provider Information | |||||||||
| NPI: | 1588602122 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PENDSE | ||||||||
| FirstName: | PRABHAKAR | ||||||||
| MiddleName: | DAMODAR | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 602484 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282602484 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9108155830 | ||||||||
| FaxNumber: | 9108155698 | ||||||||
| Practice Location | |||||||||
| Address1: | 2131 S 17TH ST | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284017407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9108155830 | ||||||||
| FaxNumber: | 9108155698 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2006 | ||||||||
| LastUpdateDate: | 02/07/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 17733 | NC | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 4098357 | 01 | NC | AETNA | OTHER | 1588602122 | 05 | NC | MEDICAID | 183728 | 01 | NC | MEDCOST | OTHER | 8966735 | 05 | NC | MEDICAID | 66735 | 01 | NC | BCBS NC | OTHER |