Provider Demographics
NPI:1023164399
Name:MCKENDALL, BENJAMIN S (MD)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:S
Last Name:MCKENDALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2435 S VOLUSIA AVE
Mailing Address - Street 2:SUITE D-1
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-7643
Mailing Address - Country:US
Mailing Address - Phone:386-775-7733
Mailing Address - Fax:
Practice Address - Street 1:2435 S VOLUSIA AVE
Practice Address - Street 2:SUITE D-1
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-7643
Practice Address - Country:US
Practice Address - Phone:386-775-7733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0027026207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL058145300Medicaid
FL1001070002Medicare NSC
FL406183743Medicare PIN
FL59266Medicare PIN
FL058145300Medicaid
FL59266AMedicare PIN
FL180003616Medicare PIN