Provider Demographics
NPI:1982991501
Name:BEENKEN, KANDICE RENEE (DO)
Entity Type:Individual
Prefix:
First Name:KANDICE
Middle Name:RENEE
Last Name:BEENKEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3750 CONVOY ST STE 201
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-3770
Mailing Address - Country:US
Mailing Address - Phone:858-278-8031
Mailing Address - Fax:858-278-1708
Practice Address - Street 1:3750 CONVOY ST STE 201
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-3770
Practice Address - Country:US
Practice Address - Phone:858-278-8031
Practice Address - Fax:858-278-1708
Is Sole Proprietor?:No
Enumeration Date:2011-07-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101019407207X00000X
NVDO2030207X00000X
CA20A15340207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20A15340OtherCA MEDICAL LICENSE
MI5101019407OtherMEDICAL LICENSE NUMBER
NVDO2030OtherNV MEDICAL LICENSE
NV1982991501Medicaid
NV1982991501Medicaid