Provider Demographics
NPI:1073507190
Name:PRENDIVILLE, PAUL L (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:L
Last Name:PRENDIVILLE
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 1:23961 CALLE DE LA MAGDALENA
Mailing Address - Street 2:STE. 302
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-3616
Mailing Address - Country:US
Mailing Address - Phone:949-588-2020
Mailing Address - Fax:949-588-0336
Practice Address - Street 1:23961 CALLE DE LA MAGDALENA
Practice Address - Street 2:STE. 302
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-3616
Practice Address - Country:US
Practice Address - Phone:949-588-2020
Practice Address - Fax:949-588-0336
Is Sole Proprietor?:No
Enumeration Date:2005-09-02
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG73434207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G734340Medicaid
CAWG73434BMedicare PIN
CAW12044BMedicare PIN
CACK3068Medicare PIN
CA00G734340Medicaid
CAWG73434CMedicare PIN
CAW12044Medicare PIN