Provider Demographics
NPI:1043506595
Name:DEANGELIS, KENDRA DENISE (MD)
Entity Type:Individual
Prefix:
First Name:KENDRA
Middle Name:DENISE
Last Name:DEANGELIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KENDRA
Other - Middle Name:DENISE
Other - Last Name:CLEMONS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 917770
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2963 GULF TO BAY BLVD STE 267
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33759-4209
Practice Address - Country:US
Practice Address - Phone:787-285-8006
Practice Address - Fax:727-216-6560
Is Sole Proprietor?:No
Enumeration Date:2011-06-23
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME136932207WX0200X, 207W00000X, 207W00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0200XAllopathic & Osteopathic PhysiciansOphthalmologyOphthalmic Plastic and Reconstructive Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
DUPRYOtherBCBS GROUP
FLLWBRROtherBCBS
FL13809966OtherCAQH