Provider Demographics
NPI:1104806108
Name:PENDARVIS, DEREK PAUL (MD)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:PAUL
Last Name:PENDARVIS
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:PO BOX 658
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30503-0658
Mailing Address - Country:US
Mailing Address - Phone:770-718-1122
Mailing Address - Fax:770-535-7445
Practice Address - Street 1:725 JESSE JEWELL PKWY SE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3834
Practice Address - Country:US
Practice Address - Phone:770-536-2323
Practice Address - Fax:770-536-4947
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA049933208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1700231OtherUNITED HEALTHCARE
GA000904274AMedicaid
GA10045029OtherAMERIGROUP
GA52843776OtherBCBS
GA000904274BMedicaid
GA341106OtherWELLCARE
GA7816063OtherCIGNA
GA20050660OtherRR MEDICARE-GRP # CC4177
GA02BBCQMMedicare ID - Type Unspecified
GA000904274AMedicaid