Provider Demographics
NPI:1063520187
Name:RENDINA, GARY WATSON (DC)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:WATSON
Last Name:RENDINA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 ANTHONY WAYNE DR
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:PA
Mailing Address - Zip Code:19087-1428
Mailing Address - Country:US
Mailing Address - Phone:610-964-0608
Mailing Address - Fax:610-964-2745
Practice Address - Street 1:136 ANTHONY WAYNE DR
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:PA
Practice Address - Zip Code:19087-1428
Practice Address - Country:US
Practice Address - Phone:610-964-0608
Practice Address - Fax:610-964-2745
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC002016L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000124594OtherHIGHMARK BLUE SHIELD
PA0032882000OtherINDEPENDENT BLUE CROSS
PA000124594OtherHIGHMARK BLUE SHIELD
PA124594Medicare ID - Type Unspecified