Provider Demographics
NPI:1144370446
Name:PRENDERGAST, GENE DAVID (DO)
Entity type:Individual
Prefix:DR
First Name:GENE
Middle Name:DAVID
Last Name:PRENDERGAST
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:18444 N 25TH AVE
Mailing Address - Street 2:SUITE 310
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85023-1261
Mailing Address - Country:US
Mailing Address - Phone:866-974-2673
Mailing Address - Fax:866-939-2673
Practice Address - Street 1:4485 S 1-19 FRONTAGE ROAD
Practice Address - Street 2:SUITE 100
Practice Address - City:GREEN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85614
Practice Address - Country:US
Practice Address - Phone:866-974-2673
Practice Address - Fax:866-939-2673
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2015-10-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NMA-1607-11207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZD47124Medicare UPIN