Provider Demographics
NPI:1285885814
Name:DR. EDDIE PRENDERGAST OD
Entity type:Organization
Organization Name:DR. EDDIE PRENDERGAST OD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDDIE
Authorized Official - Middle Name:LEO
Authorized Official - Last Name:PRENDERGAST
Authorized Official - Suffix:JR
Authorized Official - Credentials:OD
Authorized Official - Phone:304-872-5678
Mailing Address - Street 1:651 WATER ST
Mailing Address - Street 2:
Mailing Address - City:SUMMERSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26651-1454
Mailing Address - Country:US
Mailing Address - Phone:304-872-5678
Mailing Address - Fax:307-872-5697
Practice Address - Street 1:651 WATER ST
Practice Address - Street 2:
Practice Address - City:SUMMERSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26651-1454
Practice Address - Country:US
Practice Address - Phone:304-872-5678
Practice Address - Fax:307-872-5697
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-01
Last Update Date:2008-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV666D152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0150410000Medicaid
WV0150410000Medicaid
WV0371540001Medicare NSC
WVT-32503Medicare UPIN