Provider Demographics
NPI:1710097613
Name:RENDON, RAYMOND RUDOLPH (BCO)
Entity Type:Individual
Prefix:MR
First Name:RAYMOND
Middle Name:RUDOLPH
Last Name:RENDON
Suffix:
Gender:M
Credentials:BCO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2039 FOREST AVE STE 206
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-4815
Mailing Address - Country:US
Mailing Address - Phone:408-297-4850
Mailing Address - Fax:408-297-0676
Practice Address - Street 1:2039 FOREST AVE STE 206
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-4815
Practice Address - Country:US
Practice Address - Phone:408-297-4850
Practice Address - Fax:408-297-0676
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADXX00008FMedicaid
CA0536440002Medicare NSC