Healthcare Provider Details

I. General information

NPI: 1588636765
Provider Name (Legal Business Name): KEVIN J PRENDIVILLE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2006
Last Update Date: 04/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 COBALT DR
DANA POINT CA
92629-5906
US

IV. Provider business mailing address

11 COBALT DR
DANA POINT CA
92629-5906
US

V. Phone/Fax

Practice location:
  • Phone: 949-388-9718
  • Fax: 949-388-9215
Mailing address:
  • Phone: 949-388-9718
  • Fax: 949-388-9215

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberG45074
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: