Provider Demographics
NPI:1124045935
Name:BENDEREV, THEODORE VAL (MD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:VAL
Last Name:BENDEREV
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 1:26732 CROWN VALLEY PKWY
Mailing Address - Street 2:SUITE 327
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-6306
Mailing Address - Country:US
Mailing Address - Phone:949-364-4400
Mailing Address - Fax:949-364-2829
Practice Address - Street 1:26732 CROWN VALLEY PKWY
Practice Address - Street 2:SUITE 327
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6306
Practice Address - Country:US
Practice Address - Phone:949-364-4400
Practice Address - Fax:949-364-2829
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG43662174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA 89787Medicare UPIN
CAWG43662CMedicare ID - Type Unspecified