Provider Demographics
NPI:1447298567
Name:SHANDERA, KEVIN CHARLES (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:CHARLES
Last Name:SHANDERA
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 1:39000 BOB HOPE DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-3221
Mailing Address - Country:US
Mailing Address - Phone:760-346-8555
Mailing Address - Fax:760-346-8666
Practice Address - Street 1:39000 BOB HOPE DR
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-3221
Practice Address - Country:US
Practice Address - Phone:760-346-8555
Practice Address - Fax:760-346-8666
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC1462452088F0040X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No2088F0040XAllopathic & Osteopathic PhysiciansUrologyUrogynecology and Reconstructive Pelvic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC24861OtherPARTNERS PROVIDER #
NC340016947OtherRAILROAD MCRE PROV #
NC1074UOtherBCBS NC INDI PROV #
NC2251912CMedicare ID - Type Unspecified
NC24861OtherPARTNERS PROVIDER #
NC1074UOtherBCBS NC INDI PROV #