Healthcare Provider Details

I. General information

NPI: 1447298567
Provider Name (Legal Business Name): KEVIN CHARLES SHANDERA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 03/08/2022
Certification Date: 03/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39000 BOB HOPE DR
RANCHO MIRAGE CA
92270-3221
US

IV. Provider business mailing address

39000 BOB HOPE DR
RANCHO MIRAGE CA
92270-3221
US

V. Phone/Fax

Practice location:
  • Phone: 760-346-8555
  • Fax: 760-346-8666
Mailing address:
  • Phone: 760-346-8555
  • Fax: 760-346-8666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2088F0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Urology) Physician
License NumberC146245
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberC146245
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: