Provider Demographics
NPI:1184282048
Name:KENDALL, EMERSON (DO)
Entity type:Individual
Prefix:
First Name:EMERSON
Middle Name:
Last Name:KENDALL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 E MAIN ST APT 306
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53703-2905
Mailing Address - Country:US
Mailing Address - Phone:616-560-4730
Mailing Address - Fax:
Practice Address - Street 1:525 E MAIN ST APT 306
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53703-2905
Practice Address - Country:US
Practice Address - Phone:616-560-4730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-04
Last Update Date:2024-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5151013622207W00000X
WI81140207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5151013622Medicaid