Provider Demographics
NPI:1306947452
Name:KENDRICK, MARK DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:DAVID
Last Name:KENDRICK
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:790 DUNLAWTON AVE
Mailing Address - Street 2:SUITE E
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-9279
Mailing Address - Country:US
Mailing Address - Phone:386-760-1877
Mailing Address - Fax:386-760-2791
Practice Address - Street 1:790 DUNLAWTON AVE
Practice Address - Street 2:SUITE E
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-9279
Practice Address - Country:US
Practice Address - Phone:386-760-1877
Practice Address - Fax:386-760-2791
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2009-10-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLME0057676207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL080164321Medicaid
FL59-3667262OtherTAX ID#
FL080164321OtherRAILROAD MEDICARE
FLMEDICARE GROUPOther45360
FL0575838OtherAETNA
FL080164321OtherRAILROAD MEDICARE
FL23948XMedicare PIN