Provider Demographics
NPI:1306910906
Name:HENDRICKSON, BEVERLY R (MD)
Entity type:Individual
Prefix:DR
First Name:BEVERLY
Middle Name:R
Last Name:HENDRICKSON
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:30230 RANCHO VIEJO RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:SAN JUAN CAPISTRANO
Mailing Address - State:CA
Mailing Address - Zip Code:92675
Mailing Address - Country:US
Mailing Address - Phone:949-493-7337
Mailing Address - Fax:949-373-1300
Practice Address - Street 1:30230 RANCHO VIEJO RD
Practice Address - Street 2:SUITE A
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675
Practice Address - Country:US
Practice Address - Phone:949-493-7337
Practice Address - Fax:949-373-1300
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG40908208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0081160Medicaid
CAGR0081160Medicaid