Individual
DESIREE BUEHLER PENDERGRASS
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
2500 N STATE ST, JACKSON, MS 39216-4500
(601) 815-8982
Mailing address
2500 N STATE ST, JACKSON, MS 39216-4500
(601) 815-8982
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
24712
MS
208000000X
Pediatrics Physician
H4609
TX
2083P0901X
Public Health & General Preventive Medicine Physician
24712
MS
2083P0901X
Public Health & General Preventive Medicine Physician
H4609
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
05359595
—
MS
01
—
08907561
NM MEDICAID
TX
01
—
132232307
TMHP
TX
01
—
155349101
FIRSTCARE MEDICAID
TX
01
—
200101350A
OK MEDICARE
TX
01
—
8G6058
BC/BS
TX
01
—
8J1510
MEDICARE
TX
Enumeration date
10/03/2006
Last updated
02/17/2017
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