Provider Demographics
NPI:1952300667
Name:SHUMWAY, KENDALL PRATT (DP M)
Entity Type:Individual
Prefix:DR
First Name:KENDALL
Middle Name:PRATT
Last Name:SHUMWAY
Suffix:
Gender:M
Credentials:DP M
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11555 1/2 POTRERO RD
Mailing Address - Street 2:
Mailing Address - City:BANNING
Mailing Address - State:CA
Mailing Address - Zip Code:92220-6946
Mailing Address - Country:US
Mailing Address - Phone:951-849-4761
Mailing Address - Fax:
Practice Address - Street 1:11555 1/2 POTRERO RD
Practice Address - Street 2:
Practice Address - City:BANNING
Practice Address - State:CA
Practice Address - Zip Code:92220-6946
Practice Address - Country:US
Practice Address - Phone:951-849-4761
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4447213E00000X
AZ0483213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ23199Medicare ID - Type Unspecified
AZU70632Medicare UPIN