Provider Demographics
NPI:1558309054
Name:PRENDIVILLE, STEPHEN A (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:A
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 1:9407 CYPRESS LAKE DR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-0910
Mailing Address - Country:US
Mailing Address - Phone:239-437-3900
Mailing Address - Fax:239-437-3969
Practice Address - Street 1:9407 CYPRESS LAKE DR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-0910
Practice Address - Country:US
Practice Address - Phone:239-437-3900
Practice Address - Fax:239-437-3969
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME81906174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
H37916Medicare UPIN
FLK4568Medicare ID - Type Unspecified