Provider Demographics
NPI:1588636765
Name:PRENDIVILLE, KEVIN J (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:J
Last Name:PRENDIVILLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:11 COBALT DR
Mailing Address - Street 2:
Mailing Address - City:DANA POINT
Mailing Address - State:CA
Mailing Address - Zip Code:92629-5906
Mailing Address - Country:US
Mailing Address - Phone:949-388-9718
Mailing Address - Fax:949-388-9215
Practice Address - Street 1:11 COBALT DR
Practice Address - Street 2:
Practice Address - City:DANA POINT
Practice Address - State:CA
Practice Address - Zip Code:92629-5906
Practice Address - Country:US
Practice Address - Phone:949-388-9718
Practice Address - Fax:949-388-9215
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2010-04-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG45074207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZB57528Medicare UPIN
AZZ107716Medicare PIN