Provider Demographics
NPI:1376603894
Name:PENDERGRAST, W. JEFFERSON JR (MD)
Entity type:Individual
Prefix:DR
First Name:W. JEFFERSON
Middle Name:
Last Name:PENDERGRAST
Suffix:JR
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 1:2505 FLAIR KNOLL CT NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30345-1311
Mailing Address - Country:US
Mailing Address - Phone:404-636-2332
Mailing Address - Fax:
Practice Address - Street 1:2505 FLAIR KNOLL CT NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30345-1311
Practice Address - Country:US
Practice Address - Phone:404-636-2332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA015409174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist